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        Working on the Front:  Ethics in Rehabilitation of Veterans.

        February 29, 2008.

        Held at Southern University, Baton Rouge, Louisiana.



             >> DR. KUNDU:  Good morning.  Are we ready?

        Good morning and welcome to the symposium that is being webcasted by the

   ILRU in Houston, so we'll be hearing back and forth from them throughout the

   country, and also a doctor from the national clearinghouse on training material,

   so the national clearinghouse on Utah University and, Laurel, you want to say

   something how this will be working out?  Go ahead.

             >> LAUREL:  Thank you, Madan.  Greetings to all of you from Houston,

   and all of you around the country who are listening via this webcast.  For the

   people listening, a couple of points on the mechanics.  First of all, if you

   have any problems whatsoever with your connection, do not hesitate to call our

   office.  We have technical assistance ready to handle your call.

        The telephone number is (713)520-0232.  That's a voice and a TTY number.

   And also there may be opportunities to ask questions during this session, so

   we'll handle that this way:  When you have a question, you click on your E-mail

   program, address it to ILRU at ilru.org and just E-mail in your question and

   we'll hold it here until Madan and his colleagues are ready to take that

   question.

        We advise you on -- you see on the web page that we have a list of the

   agenda and a list of presentations, what would be called handouts in another

   world.  They are PowerPoint presentations, et cetera.  You can either click on
                                             2

   those and follow along as the presenter's go and you can download it of course

   and use it as regular handouts.  We would ask the presenters to reference the

   page or slide on which they are participating so those of us can follow along

   online.

        We're very pleased to have been invited by Madan and Alo to use our

   webcasting to make this important conference available to people around the

   world.  Currently, we have around 70 people listening in and, Madan, we're very

   pleased to work with you on this.

             >> DR. KUNDU:  Thank you, Laurel.  We ready to go?

             >> LAUREL:  Yes, sir.

             >> DR. KUNDU:  All right.  This is a new experience.  It's the first

   time we're doing it.  I'm sure it's a good experience.  (inaudible) counseling

   academic and professional society international, we have a chapter here called

   (inaudible).  The purpose of this society is to promote scholarship, research

   and excellence in counseling and (inaudible) in the field of counseling.  So

   keeping in this model of this society, every year we conduct an annual

   professional symposium along with the ceremony of the students.  It will address

   the issue of working on the front, ethics in rehabilitation of veterans.

        You've heard of veterans returning from Afghanistan and Iraq and similarly,

   I was in Tunisia last October and we had a conference.  There are 800 million

   people with disabilities in the world and the African continents, has many

   disabilities increasing because of the war, particularly the land mine victims

   and children who are victims of land mines.  So we have some data that are

   number of service members that goes from more than 55,000.  A high portion of

   these veterans have experienced spinal cord injuries, amputation and various
                                             3

   other injuries.

        Because of terrorism, the potential to drive PTSD quite high.  There are

   health conditions after serving in conflicts.  The purpose of the symposium is

   to raise public awareness of the conditions of returning veterans with

   disabilities and what can be done to improve the quality of their community

   reintegration.  We have a problem here in Baton Rouge and New Orleans and we'll

   hear from local speakers on the veterans administration and what we are doing

   with returning veterans.  Today we have a cutting edge topics, Allied health

   professionals.  Throughout the day, we are privileged to hear from six experts

   on this topic and we'll have opportunities to interact with them, to take

   advantage of this opportunity and to take part in deliberation throughout the

   day, ask questions, receive answers from our speakers.

        I would like to now invite the dean of the College of Sciences, Robert H.

   Miller to make some remarks and he'll be followed by the dean of the graduate

   school, James Llorens and then followed by Teresa Milner.  This program is

   sponsored by many organizations, the Department of Rehabilitation Services and

   Disability Studies, National Council on Rehabilitation Education, Louisiana

   Rehabilitation Services, project with (inaudible).  Dr. Miller, will you please

   come forward.

             >> DR. MILLER:   Good morning.  I'm happy to welcome everyone to

   this -- I'm happy to welcome everyone to this 20th Sigma Chai Counseling

   Academic Professional Honor Society meeting.  This is one of the events that is

   for real.  In the 43 years I've been here, I've seen conferences start and go

   for a couple of years and then stop, but this is one of the sustaining programs.

        For those of you who don't know, the Department of Rehabilitation and
                                             4

   Disability Studies was under the Department of Psychology for 20 years and when

   they found out they couldn't rehabilitate psychology people, they separated out

   and decided that they would work on something more realistic.  So I'm happy to

   welcome you.

        This is a timeless subject here, rehabilitation of veterans.  I'm probably

   the only one in here who remembers all of the modern wars starting with World

   War II -- yeah, World War II.  I grew up then.  I remember when Japan bombed

   Pearl Harbor.  And for those of you that don't know, the military was held in

   high esteem.  Hollywood promoted the military, war bonds and that type of thing.

   There was a draft Army then, and I did go to be examined.  I almost got in, but

   I think what saved me is that, you know, I really did -- I really never knew my

   left from my right, okay?  The only way that I know my left from my right is

   that I got a burn on my hand when I was little, and my mother told me the hand

   with the burn on it, that's your left hand.

        So when I went to be examined and they told me to turn right, I paused and

   I looked at both hands.  He said turn right.  I said, that's what I'm trying to

   do, but I had to see which hand the scar was on so I would know to turn in the

   opposite direction.  So I think he decided that I wasn't for the military.

        But at any rate, particularly for the later wars like Desert Storm -- the

   Korean War, Vietnam, more recently Desert Storm and Afghanistan, the current war

   we're in, the veterans are really -- it should be a no brainer that our veterans

   just aren't being treated well in terms of the assistance that they get and the

   rehabilitation that they get.  I like to watch Fox News channel a lot.  I listen

   to O'Reilly -- and anyone who knows he is conservative and John Kerry is on the

   opposite end of the spectrum, but they are great both Americans and they put
                                             5

   forth a feel to get better benefits for veterans.  It's just unacceptable, for

   example, that we have something like in the case of the Walter Reed Hospital,

   those things like that, that just shouldn't be going on in a nation such as

   ours.

        So I want to welcome you again.  This is a timeless subject and I hope that

   this will be beneficial to everyone and that really we can do something about

   the current status of the treatment that our veterans get.

        In this day and age, the war we're fighting now, they don't even get a

   chance to get an opportunity to get rehabilitated.  I think I heard on the news

   last night that a fellow got his leg shot off or was amputated and he's back

   over there fighting.  So this is the type of situation we have.

        So again, welcome, and I hope that this will be a productive day for

   everyone.  Thank you.

        [APPLAUSE]

             >> DR. LLORENS:  Good morning.  I'll try and get this straight with

   all the technology and good morning I guess to all of those that are joining us

   from the world of the Internet and technology and everything else.  Again, let

   me introduce myself.  I'm Jim Llorens, dean of the school, and I want to take

   this opportunity to welcome you to the university, welcome you to this event,

   and I'd like to acknowledge Dr. Kundu.  They have consistently put together very

   timely and very good symposia and training topics and I think that we should

   recognize their contributions in the discipline and the training of professional

   developments throughout this state and throughout this country.  As you know,

   they have also recently in the past two years started an online masters program

   so we are now training people from across the country in rehabilitation and
                                             6

   disability studies.  And I think the department is one of those unknown gems

   within the state that people should really be aware of and I'd like to take this

   opportunity to acknowledge them for that.

        I'd like to thank the association for this very important topic for this

   symposium.  I think we're all aware of the conditions that veterans are facing

   as they return from Iraq and Afghanistan.  On a very personal basis, I'd like to

   also thank you for this topic.  As a veteran and as a veteran of the Vietnam

   conflict, I realized when we returned and realized some of the challenges that

   all of our veterans faced, and it is really disconcerting to see news reports

   and read about the things that they faced.  I thank you personally.  I thank you

   on behalf of all veterans for this timely topic and wish you great success for

   the day.

        I know that you will have a successful symposium.  I thank you for coming

   here.  I thank Dr. Kundu for this topic and just again on behalf of the graduate

   school, on behalf of Southern University, welcome.  Thank you and I wish you

   great success today.

        [APPLAUSE]

             >> MS. MILNER:   Good morning everyone.  I'm Teresa Milner and I'm a

   Bureau Administrator with Louisiana Rehabilitation Services.  I'm here on behalf

   of our director, Robert Starks, who couldn't be here this morning and I would

   like to take this opportunity to welcome you all and to thank you for allowing

   L. R. S. to participate.  The topic of ethics in rehabilitation of veterans

   touches the very core and foundation of the L. R. S. program.  Our flagship

   program, the vocational rehabilitation program was established specifically to

   address the needs of veterans returning home from World War I.
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        Over time, the vocational rehabilitation program has expanded to serve

   individuals with all types of disabilities.  And for more than 81 years, L. R.

   S. as a part of the rehabilitation community has provided various services to

   make a difference in the lives of individuals with disabilities and to increase

   the economy of the states and make a difference in the lives of those we serve.

        So I just want to take this opportunity to applaud all of you as part of

   that rehab community for the efforts that you make in this endeavor and look

   forward to continuing this most valuable mission.

        And in addition, if any of you would like further information regarding the

   services that Louisiana Rehabilitation Services provides, we can be -- you can

   go to our website at www.dss.state.la.us and view all of the information on our

   website.  That's a long one, Bobby.  Thank you all for having us.  Okay?

        [APPLAUSE]

             >> DR. KUNDU:  Thank you, Dean Miller and Dean Llorens and Ms. Milner.

   I would like to present our first speaker, but before I do that, I'd like to

   acknowledge Alo Dutta for selecting the topics and she had a hard time, so she

   did quite a bit to find the right speaker for today.  So please acknowledge

   Dr. Dutta and faculty and graduate students.

        I have a pleasure of introducing our first speaker, Ms. Dinah Cohen who is

   the director of the Department of Defense, Computer Electronic Accommodations

   Program.  Yesterday I was looking into the presentations for CAP.  I don't see

   any other program with an acronym of CAP.  It ensures that employees,

   beneficiaries and members of the public with disabilities have equal access to

   services and employment.  So under her leadership, CAP has won numerous awards

   since its inception in 1990.
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        In the past year, Ms. Cohen has initiated a program to provide assistive

   technology and accommodation support to wounded military service members.

   Ms. Cohen is the 2005 service award recipient of the Best Leadership Award, and

   the Department of Defense Exceptional Civil Service Award for her leadership

   impacting on the development, acquisition and management of information

   technology in the federal government.

        So Ms. Cohen is a certified rehab counselor, how nice, one from our field.

   She received her MS in counseling psychology from the State University of New

   York.  Please welcome Ms. Cohen.

        [APPLAUSE]

             >> MS. COHEN:  Good morning everyone.  Okay, I'm from the Department

   of Defense.  I came from Washington I need a little more excitement than that.

   Good morning everyone!  All right.  It's a thrill to be with the people of my

   kind, people from a rehab background.  So I need to see a little show of hands,

   how many of you are currently in a rehab counseling program?  All right.  Fresh

   blood.  I love it.  (Laughter).

             >> MS. COHEN:  How many of you have already gone into practice?  Okay,

   a few of you.  We'll do what we can with you folks.  All right, how many of you

   have ever heard of CAP before today?  All right.  We've got two.  That's not too

   bad.  My goal today is to really address two different audiences, first I want

   to start off with talking about what we all need to do better in employment of

   people with disabilities and how you in the rehab field need to help me to make

   that happen.

        Then I'm going to switch gears and talk specifically about what we're doing

   for our wounded service members as they return from the global war on terror.
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   With that, let's go to the first slide and give you a little overview.

        The program has been around for awhile, 17 years old plus, and it was

   really established in the Department of Defense to serve as a centrally funded

   program to buy and pay for assistive technology to ensure that our employees

   with disabilities in the Department of Defense can access today's information

   environment.  As we move to an information environment, we had noticed that many

   of our employees with disabilities would need extra equipment.  So the first

   question that came to management's mouth is who is going to pay for that?  And

   so we decided the smart thing to do is to centrally fund it, centrally manage

   all of the peripheral equipment that would allow a person with a significant

   disability to be part of today's information environment.

        Our success -- it became a presidential task force on employment of persons

   with disabilities during the Clinton administration and they recommended to

   President Clinton that if he wanted to have an impact on the employment of

   people with disabilities in the federal sector, he needed to have a CAP-like

   model in the federal government.  So he turned to CAP and we were expanded to

   now serve all of federal government.

        I now do this for all of the Department of Defense and all of the Armed

   Services and 65 other federal agencies.  So if you're working with the V.A., if

   you're going to place a disabled veteran in interior or agriculture or any of

   those federal agencies and they need assistive technology, they'll get it free

   from CAP.  So you as a rehab counselor need to know the tools on how to do your

   jobs better.

        And one of the things that I've always been kind of concerned about is that

   rehab counselors don't know the tools out there.  When it comes to placing
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   people with disabilities, they are not as smart or as prepared as I would like

   them to be on assistive technology and how to market people with disabilities

   and on the places in which they can get these tools.  So that's one of my goals

   today is to give you a couple more tools for your toolbox so when you start to

   place people with disabilities in the federal sector, you would know who you can

   turn to to make sure that you have that hand-off where you can have them have

   the technology they need to be successful.

        Since my inception, I have now filled 61,000 requests for accommodations.

   It keeps me busy.  It keeps me off the streets.  My mission -- very simple

   mission.  I'm with the Department of Defense, what's your mission?  My mission

   is to provide the assistive technology and accommodations to ensure that people

   with disabilities have equal access to the information environment and

   opportunities in the Department of Defense and throughout the federal

   government.

        And for you rehab counselors who are going out and starting your career,

   I'll say this once, it's a little defensive, but hey, we're all family.  This is

   Baton Rouge.  I got a call that said, hey, do you hire people with disabilities?

   I still hear that.  And unfortunately there are some in the audience who say why

   not?  I don't hire people with disabilities, I hire program managers.  I hire

   computer specialists.  I hire accountants.  I hire information technology

   specialists.  I do not hire people with disabilities.  Tell me what they can do,

   not their disability.  And I'm one of the good ones.  I'm going to listen to

   your speech.  Most managers go, no, and they'll hang up.  Remember, this is not

   your job to sell the disability.  It's your job to sell me a qualified person

   that sits in my employment environment, that has the skill sets I need, and
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   anything less than that is not worth my time.  So if you hear nothing else, hear

   that.  I hear too many rehab professionals with masters and Ph.D.'s selling the

   wrong thing.  I want talented people.  I am a person with a disability.  I went

   through rehab.  I am a certified rehab counselor.  I know how talented we are.

   And unfortunately, you know, I don't know he got the bio.  I just received --

   for the first time someone in this field received the Service to America Medal

   which I'm very proud of, but that's because I'm not selling disability.  I'm

   selling the best people to do the jobs and they may have a disabling condition

   that you need to know about.

        So let's make sure that we're using the right terms and we do what's best

   for our customers.  Next slide.

        What do we do?  The first thing we do is we provide the services of

   assistive technology.  We buy, we pay for it and get it to the user.  We feel

   like doing this we have leveled the playing field for people with disabilities

   because unfortunately no matter how many things we added to attitudinal

   barriers, we know there are managers there who would still not want to hire

   people with disabilities and the one thing they'll throw back in our faces is

   the fact that accommodations cost money.  Who is going to pay?  So my answer is

   I'm going to pay.  So now what's your excuse?  We need to make sure we know both

   the latest of assistive technology and as you market that qualified person that

   may have a disabling condition, that may need assistive technology, you know the

   person, you know the skill set and you know the assistive technology.  Even if I

   pay for it, you've got to make sure that employee goes to that interview

   prepared to answer those questions.

        And they know the assistive technology they need.  And they know what the
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   manager is going to ask them.  And they are comfortable with that.  I'll pay for

   the accommodations once they come to federal government, but they have to be

   comfortable explaining it because they have -- okay, side line.  This young

   generation, oh, my God!  I feel like two titles, director of the computer

   electronics program and director of a day care center.  (Laughter).

        The young folks have been -- oh, maybe a little bit spoiled, a little bit

   protected, so when they go to an employer, they think -- no, because they assume

   it's going to be there.  This is the real world.  And they have to be prepared

   to explain what they need, how they are going to use it and how they are going

   to perform their job.  So we need to make sure as we promote the employment of

   people with disabilities, they have these skill sets.

        Many individuals that I accommodate are not people that are born with

   disabilities, but they come disabled later in life.  We do a lot of needs

   assessment and help them identify what assistive technology or what

   accommodations they will need now due to their new disabling condition.

        We help with providing the installation and integration of that technology

   and this is really critical as we move quickly through the information

   environment.  Many organizations are way ahead from other ones when it comes to

   technology.  Of course the Department of Defense will be the best and the leader

   of it because that's kind of what we do, so we need to make sure we understand

   the information environment that that employee is going to be so that technology

   will work there.  So we always help with installation and integration.

        We provide a lot of training on disability management and accessible

   environments.  Now, I personally believe (inaudible) -- hello.  I believe I

   provide some of the best training on disability management in the state of
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   Hawaii and on the west coast.  So if you need me to go out there where the sun

   is really warm, let me know.  (Laughter).

        We need to make sure that we're training all of the managers on how to do

   this right.  I do this in support of them complying with federal legislation.

   As federal managers, as directors, whether you're the university, private

   sector, public sector, we have an obligation to be in compliance with federal

   laws that deals with the issue of employment of people with disabilities.  So

   whether you're complying with the ADA or you're complying with the Rehab Act, we

   need managers to understand there is legislation that requires them to be

   standing forward and to be a real champion of employment of people with

   disabilities.

        I do all of this in the hopes of assisting in the recruitment, the

   placement, the promotion and the retention of people with disabilities and my

   newest customers, my returning wounded service members.

        So let me just do a snapshot of what I mean by assistive technology and

   this is truly just a snapshot.  We're talking about the technology that connects

   to a computer environment, a telecom environment, because let's face it, that's

   what we all use.  How many of you are computer scientists, computer programmers

   or engineers, raise your hands?  Okay.  How many of you have a computer on your

   desk, raise your hands?  It's not just for those nerds anymore.  If they expect

   us to do those webcasts and printing and reporting, we're doing this off a

   computer.  So it's getting harder and harder to find a job, whether it's for a

   person with a disability or not, that doesn't include their ability to access

   the computer environment, which is why it is so important for all of you to be

   knowledgeable about all that information input and output tools because we're
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   all using them.

        When it comes to computer input tools, being rehab professionals, what's

   the No. 1 disabling condition in America today -- yell it out.  Carpal tunnel

   syndrome.  Whether you have a disability or not, so many people are developing

   carpal tunnel syndrome and are not as productive because they now have a

   disabling or functional limitation.  So we need to say, well, what do we need to

   provide that person so they can be able to continue to be productive?  So we

   provide different types of keyboards, different types of mice and on the high

   end, voice recognition technology where they can talk to their computers.  And

   if you haven't seen that technology or you think you've seen it, but you haven't

   seen it recently, time to get educated, because that is now a very powerful tool

   and a tool that has been able to work for many environments, including our vets.

   Computer output devices -- how many of you have noticed that over the years the

   print in the phone book has gotten a lot smaller?  Oh, yeah, right.  It can't be

   me.  It's the print in the phone book.  They decided to make it smaller.

   Obviously some of us will start to develop different types of functional

   limitations when it comes to our vision.  I will be going for some cataract

   surgery myself soon enough and it's one of those things that happens to us.  How

   do we ensure that people with visual disabilities have equal access to this

   environment?  We become familiar with the screen readers.  We become familiar

   with magnification tools.  We become familiar with the hardware solutions and

   the software solutions.  We become familiar with Braille terminals, we become

   familiar with the Braille notetakers.  We become familiar with these tools so

   when we start to place or try to be that advocate for employment for that

   disabled veteran, for that employee with a disability, we know the tools.  So if
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   you're going to place them in other places, you need to know that.  That is your

   job.  And I need you folks to step up on that role because I haven't seen it.

        And hopefully it's not true for you folks, but I'll be honest, I haven't

   seen it.  I have not seen rehab professionals as knowledgeable as they need to

   be and should be when it comes to these kind of tools.

        Telecom devices -- many of us start to lose our hearing, so we need a lot

   of telecom for people who are deaf and hard of hearing.  Of course we have the

   TTY.  How many of you are familiar with TTY's?  Every hand should be up.  Every

   hand should be up.  Do you have TTY's in your offices?  Do you advertise that

   number?  That's where we fall short.  Oh, I got it.  It's in a box over there.

   Have you used it?  Well, I don't know, I have to wait for someone to install it.

   Why don't you just plug it in?  Well, do people know how to call you?  Well, da,

   da -- if you don't advertise it, what you have done, and I would imagine a

   school like this would understand this better than many other schools, you have

   said we don't want you.  You are a minority population we don't welcome.  We

   don't advertise it because we don't want you folks to call.  Is that the message

   you want to send?  Think about the verbiage you're using every time you don't

   include a population.

        This is what we do sometimes whether you are aware of it or not.  So we

   need to make sure we don't do that.  Video communication tools -- now it's the

   new technology where you can sign on your computer using a web camera, federal

   relay service and they can use their native language and that is what they want.

   Do you know about it?  Are you aware of it?  And are you ready to explain it to

   a manager when you place a person who is deaf or hard of hearing?  That's your

   challenge.
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        Assistive technology devices -- this is becoming one of those tools that

   many of us will use.  I know I have lost some of my hearing over the years.

   I've lost my hearing because I go to too many rock concerts.  And I know the

   only way to really enjoy Tina Turner is to be next to the amplifier, so I have

   lost my hearing over the years.  And I have noticed that I hear women's voices

   better than male voices, and I hear male bass voices the best.  I've lost the

   range of hearing that is comparable to probably a male tenor voice.  And after

   25 years of marriage, I can hardly hear my husband's voice at all.  (Laughter).

        If you find that you are now developing some hearing loss, if your

   co-workers, colleagues, employees, clients, customers have that hearing

   challenge, let's not put them in the situation where they can't be competitive

   because they cannot hear well.  So assistive listening devices can be a very

   powerful tool, including amplification devices for the phone.  This is what we

   need to know to be sure that person has the ability to stay competitive.

        Captioning -- how many of you in your profession or as a university use

   DVDs and other types of things for training?  Okay, are they captioned?  Some

   yes, here are some no.  And this is one of those things that, again, reinforces

   how many people are we really saying are welcome for this training opportunity.

   And so this has really been a little bit of a challenge to start to look at how

   we can include captioning in more of our materials.

        I remember many years ago that I was talking to a group of people and the

   law had just passed that requires all TV's that were manufactured in the United

   States that were 13-inches or larger to have that internal chip that would allow

   someone to be able to watch the captioning if that show had been done that way

   by turning a switch and now you see it on all the TV's.  The conversation was
                                            17

   between two people.  One was deaf, the other one was not deaf.  The nondeaf

   person turned to the deaf person and says, you know, I really resent that I

   could spend five dollars more so you people can watch TV so you people can watch

   captioning.  The deaf woman just smiled and said, oh, don't feel so bad.  I've

   been paying for your volume control for years.  She never used it.

        We need to make sure that again we're always one step ahead, always know

   what the latest technology is and what they are doing.  Anybody can tell me --

   yell it out if you can -- where is the No. 1 public venue that always has their

   TV's on caption mode?  Sports bars.  Let's go for another drink.  You got it.

   Sports bars.  Do you think that sports bars really care about deaf and hard of

   hearing people?  No, it's when you're in the sports bars, you're all deaf and

   hard of hearing.  It's the only way to know what's going on on that game is to

   watch the captioning.  So once again, we have a tool that of course is good for

   people who are deaf and hard of hearing, but it's also good for people whose

   English is not their native language.  It's wonderful for people with learning

   disabilities and people who are functionally illiterate.  People learn better if

   they can hear and see the words at the same time.  It becomes a very powerful

   tool.

        This is a snapshot of what I've done over the years and you can see the

   growth in people with dexterity disabilities and people who now have cognitive

   disabilities and that is probably directly related to what we're doing with our

   wounded service members and I'll address that in a moment.  The numbers keep on

   growing.  Accommodations are getting more sophisticated.  You need to stay on

   top of the latest assistive technology.

        I think one of the best ways to do it -- and I know they are all over the
                                            18

   state -- so go to a place that has the assistive technology on display and spend

   some time learning about it, playing with it, testing it, being as smart about

   it so you can do your job as a rehab professional.

        I have a technology center and it's located in the Pentagon.  That's where

   I do all my needs assessment and it helps that manager -- no matter how much I

   can talk -- and I can talk a lot -- and no matter how cute I am -- and I'm very

   cute -- the thing is that nothing makes a manager understand how a person with

   disability can do a job better than seeing the technology.  When they see how

   easy it is to have that piece of equipment and it's free, if they are in the

   federal sector, often the manager says, oh, that's all there is?  That's all I

   need to do?  That's all I need to provide so that person can be part of the work

   environment?  Bring them on board.  So I encourage you to go to a technology

   center and see it.

        The very first time President Bush came to the Pentagon as our commander in

   chief, the president of the United States, was to see CAP.  Obviously I was very

   thrilled.  And we had Secretary Rumsfeld join us.  President Bush came to see

   the technology center.  After he saw the technology and the technology center,

   we went to the Pentagon auditorium and he gave his what is known as the New

   Freedom Initiative speech.

        Now, I was very thrilled because after all, who signed the Americans with

   Disabilities Act?  Yell it out.  Come on, folks, this is your background.

   What's wrong with you?  Americans with Disabilities Act was signed by George

   Bush, his daddy, Bush 41, on July 26th, 1990.  This should be on the top of

   your forehead if you're in the rehab field.  Come on!  Get with the program!

        So of course his son wanted to push that kind of tone and energy also under
                                            19

   his administration.  So he comes to the Pentagon.  He gives a speech, it was a

   wonderful day, and we were very excited.  Now it's June 19th, 2001.  The

   second time he comes to the Pentagon, September 12th, 2001.  Very different

   day.  Very different reason.

        We are here to address what's happened since.  When he came that day, I

   don't think he saw that technology as being the solution for many of the people

   who we put in harm's way to keep us free.  I don't care what you think about the

   war.  We all have our opinions, but I hope there is no one in this room who does

   not believe that we should try to extend our hands and bring that service member

   home and have him have or her have a productive life.  And that's what we're

   here to talk about.

        I'm going to quickly touch on the employment lifecycle.  I'm going to

   depend on you to do better in the rehab field to make sure people have

   opportunities.  These are the areas.  When it comes to recruitment, we turn to

   rehab services to help us do our job placement and again not you specifically,

   but I've been very disappointed with the professionalism of the rehab counselors

   coming out of school.  They are selling me people with disabilities.  They are

   not selling me the people I need.  They don't know the difference, and they

   don't know assistive technology, so get on board.

        Know the laws and the regulations and the policies.  Anything less than

   that, you have failed.  You can do all the book learning you want, but when it

   comes to practical application, without these tools, you are not doing your job.

   So I'm here to encourage you to start to learn beyond what you learn in the

   classroom if this is the field you want to stay in.

        If you believe in the mission of employment of people with disabilities,
                                            20

   then these are the tools you're going to need to have.  You need to know the

   regulations.  You need to know how to do placement.  You need to know about the

   different venues, to use assistive technology.  You're going to need to know

   that if you're going to do your job as a professional.  I went through my

   program.  I didn't learn it, and that's why I'm sharing it with you.  Learn it.

   Learn it while you're still in school.  Expand your scope of opportunities.

        So we work along with disability advocacy organizations to try to find that

   qualified person with a disability.  We post things on the USA jobs, we do a lot

   of scheduling -- how many of you even know what a Schedule A hire is?  One.

   Okay.  This is special appointment authority the federal government can use to

   bring people with disabilities into the federal sector.  How do they get

   Schedule A appointment authority?  Through voc rehab.  If you guys don't know

   about it, how are we going to get it?

        If you folks don't know that you have the power to grab schedule authority

   to an employee with a disability, how am I as a manager going to take advantage

   of it?  Get on board!  Start to learn your roles and responsibilities.

        Start to make sure that you know about this so you can help me bring people

   with disabilities who are accountants, program managers, analysts on board.  I

   just hired a very high -- in the federal government, their GS system -- I just

   hired a GS 14 with a person with a disability because I walk the walk and talk

   the talk, but I didn't have any help from any of you folks and that's what I

   want to see change.  Learn the tools and get involved.  Yes, ma'am?

             >> AUDIENCE MEMBER:  (Inaudible).

             >> MS. COHEN:  Let me repeat the question because you may not have

   heard it.  The woman asked me if the Schedule A is for the person or for the
                                            21

   job?  It's for the person to do the job.  So what you need to know is both

   whether a person is a person with a disability, which makes them qualified for

   Schedule A and they are qualified to do the job they are applying for and you

   certified this person, Rosemary Clooney is qualified to do this job, and their

   disability does not impact their ability to perform the task of the job.  We can

   only get that from voc rehab, and if you guys don't know about it, we can't get

   it.  And if I spend more of my time training voc rehab counselors on their job,

   somehow I feel there is a gap here.

        You are also very much hopefully involved with the veterans hiring

   preference.  Make sure you know your tools, the rolls, the regulations to make

   my job easier because that's what you're supposed to do.  You're supposed to

   make me look good, and I look damn good, but I can look better, and that's where

   you can come in.

        Employer Assistance Referral Network, called EARN.  This is again a little

   bit more information on a Schedule A appointment authority.  Now as I mentioned,

   we get that authority from voc rehab counselors.  We changed it a little bit

   because you guys weren't doing a very good job.  I'll be honest.  Then now as H.

   R. folks can look at a person, and a person is blind or a person is in a chair,

   and we feel that person can do a job, we can bring them on Schedule A without

   going over to voc rehab because you guys didn't know how to do it and didn't

   even know it existed.  Then we figured there is no reason to prove whether this

   person is disabled or not, we can go forward, but there are enough disabling

   conditions like L. D., like some of the hidden disabilities, like diabetes,

   epilepsy, mental illness that need that voc rehab documentation because we can't

   see it.  We can't ask questions about it, but we want to bring this person in
                                            22

   competitively and what does that mean in the federal sector?  Noncompetitively

   means I don't have to post my job.  I can pretend I'm in the private sector and

   if you bring to me a qualified person that has a skill set that I need, that has

   a disabling condition, I can hire that person on the spot.

        And managers love that, but managers want to use it and they can't get it

   going because you guys don't know about it.  Let's get busy.  Let's work

   together.  Let's bridge that gap where you are the professionals, I'm the

   manager, and you are the ones who are providing me with the tools I need.

        The same thing with veterans preference, we have a lot of rules and

   regulations.  Make sure you know the latest about veterans preference if you

   want to bring back that veteran to work, private sector, public sector.  There

   is rules and regulations.  There is incentives.  Do you know them?  If not, get

   busy.

        This is a program I'm very proud of that we tried to work with (inaudible).

   We don't have a lot of success with Louisiana either.  This is where we go on to

   the campus colleges and recruit college students with disabilities.  We

   interview them.  We screen them.  We put them part of the Workforce Recruitment

   Program.  This is sponsored by the Department of Labor and Department of Defense

   and we give them employment opportunities in the government.  These are paid

   jobs.  We go to about 130 colleges all over the country.  Some colleges choose

   to participate.  Some don't.

        We like to see colleges participate because you are saying that this

   student is ready, and the only thing we require is that you have at least eight

   students for us to interview.  Now, if one school only has four and the other

   has four and one school hosts all of them, then we can come down and interview
                                            23

   them and then they have an opportunity to work because you know what another big

   issue is for our college students with disabilities, they don't have a work

   record because no one hires them.  They are not working at McDonald's and having

   those summer jobs that other people have.  So they have this resume that shows

   absolutely nothing.  We're giving them something.

        Department of Defense is so committed to this program that every year we

   sell 250 summer students.  They get jobs.  250 students get jobs in the

   Department of Defense worldwide.  We had one student that was -- he says I have

   no problem traveling anywhere.  He was able to work at our Army base in Italy.

   He's no fool.  He knew to go there.  Now, this person is deaf, but we were able

   to use video relay to have his interpreter on base.  Know the technology, know

   the skill sets, know the placement.  Do your job.

        I encourage you to get more involved with this program.  There are a wide

   variety of occupations.  We usually have 1300 students, usually about 350 or 400

   students get placed every year in the federal government.  And it becomes a

   great opportunity.  There is a picture here of a woman with a dog and obviously

   severely disabled.  She was working for me the summer that George Bush came to

   visit the Pentagon.  And I gave her the assignment of putting together the

   briefing slides for the president.

        And you know I knew she could do it because after all she was working on

   her second masters.  She's very bright.  She's quite creative.  So I knew this

   was not going to be a big deal to give that kind of very important assignment to

   my summer student.  She gave it back to me, and I don't think I changed more

   than anything than maybe the background color or something minor.  So the day

   when the president came to visit, after he gave his speech, he goes down in the
                                            24

   auditorium and starts to shake the hands of the people in the front row and the

   second row and the third row.

        Obviously she's in the front row because of her severe disability.  We

   removed the chair so she had brought her own, how clever, and she of course had

   the dog.  So if you ever see a picture of the president bending over and petting

   a dog -- I think it used to be a long time on disabilityinfo.gov and you know

   the story of the woman and where she worked and her dog.  At the end of the

   summer you do what you do, you give your summer student a little going away

   party.  So I had a little going away party for her.  I said I assume the

   highlight of your summer was meeting President Bush.  Now, as I mentioned, this

   woman is very sharp and very bright.  And her response was, no, Dinah, it was

   meeting you.  She's one sharp cookie which is why she's still in Washington.

   She has the skill sets.  I don't see the chair.  I don't care about the dog.  I

   care about her skill sets.

        Do not sell me a person in a wheelchair with a dog, sell me that this

   person has two masters and has the skill sets I need for my job.

        I want to talk about retention and then we'll move on.  Retention, aging

   workforce, I personally don't like the term "the aging workforce," but because

   there is a big aging work force we're always talking about how do we keep people

   productive in the work environment.

        As people get older, some of us will start to develop a disabling

   condition.  Like I said, I don't like the term aging workforce.  Especially

   since I'm blah blah years old.  I like to think of myself as getting

   chronologically gifted.  (Laughter).

        As I get gifted, I know some of us won't see as well, won't hear as well.
                                            25

   Some of us will start to walk slower.  Some of us will develop dexterity

   disabilities.  When I talk to managers all over the country, all over the world,

   I'll stand in front of them and say, and I can say this time and time again and

   always be right, that even if you've never hired a person with a disability, I

   can guarantee in writing if you got the same people working for you ten years

   from now that you have right now, some will become disabled.  Someone will be

   diagnosed with cancer, cataracts, diabetes, someone will be in a car accident,

   have a stroke, a heart attack.  Someone will be deployed and come back with a

   significant injury.

        If we are truly leaders and managers, and we want to have a productive

   workforce, all of us must know and understand accommodations.  Because if not,

   we will lose some of our most talented people.

        Healthy work practices -- this is one of the things we talk about when we

   try to talk about prevention of ergonomic related injuries and staying

   productive.  I want to touch on this for a moment on how important it is if you

   are in the rehab field, many of you will choose to stay in the rehab field, but

   deal more with the private sector, and maybe get more involved with prevention.

   And as you go into prevention, one of the things we say is, is the whole

   environment right for that person?  We should be comfortable in our environment.

   We shouldn't be forced to fit into it.  It should fit us.  That's the concept of

   ergonomics.

        I remember when I moved into my new office and I was really excited because

   I have this beautiful office.  I got the big mahogany desk.  I got the big

   credenza, the big picture window with all the smoke of 9/11.  I go, all right,

   you've arrived.  And then I sat at my desk and I noticed something.  Who do you
                                            26

   think they expected to be in this executive office?

             >> AUDIENCE MEMBER:  A man.

             >> MS. COHEN:  How tall?

             >> AUDIENCE MEMBER:  (Inaudible).

             >> MS. COHEN:  Look at me, folks.  So when I sat at my desk, my feet

   didn't touch the floor.  And when I lowered my chair so my feet could touch the

   floor, I had a look about me -- not the look I was going for.

        So I had walked the walk and talked the talk.  One year I had some extra

   money and got furniture that fit me.  Now you could see this lovely face across

   the way.  You folks that go into the rehab field that's going to be working much

   more with private sector that's going to deal with workers' comp injuries, look

   at the ergonomic issues, make sure that we are returning them to a safe,

   comfortable environment.

        You'll find that many people work in cubicle environments and the reason

   they sold cubicle environments to the public and private sector is because it

   was cheap.  They also said it's because it's adjustable.  Then go ahead and

   adjust it.  Make sure it's comfortable for that user.  Let's make sure we're not

   increasing new injuries for that individual.

        I want to touch on workers' comp because many of you in the rehab field

   will go to work in workers' comp.  Any of you in that field?  Many of you will,

   trust me.  You'll start working maybe with those industries that are trying to

   help bring back that injured worker.  So we start to work along with workers'

   comp folks and dealing with the issues of how do you address the issue of

   someone getting injured on the job and coming back and returning to work?  So

   we've been doing quite a bit of that and we started to say why is it that when
                                            27

   people talk workers' comp, they don't think of them as people with disabilities

   that need to be accommodated.  They think of them as people injured on the job

   and can't return to work.

        What's with that?  Why is it the rehab professionals and people in the

   field will advocate to hire more people with disabilities who are severely

   disabled like my student Nadia and the people with back injuries go out the back

   door?  Think about that.  They are all people with disabilities.  We all -- we

   need to accommodate all of them and learn how to and do that better.

        A couple of years ago I had a person come into my technology center because

   she was severely injured on the job.  And she had -- it was not one of you, I

   hope.  She had a rehab professional tell her there was very little she could do.

   They said she had -- basically her hands were burned off because of this

   explosion.  They said, well I guess the only thing you can do now is maybe put a

   pen in your hand, tape it and hit the keyboard.  You can say oh my God, but I

   bet there are rehab professionals around here that don't know about the

   assistive technology and that was the reason for that response.

        So she comes in to my technology center.  She looks very sad.  I don't

   think there is anything you can do for me, but my husband knows about you.  I

   thought I would come.

        I don't know if I can come back to work.  Let's show you what we got.  We

   showed her the voice recognition technology.  Many of you may know about it, but

   may not have seen it recently and don't know the power.  We showed her how she

   could do an E-mail.  She gets excited.  Can you use this for a word document?

   Of course you can.  We did a word document.  She gets more excited.  Yeah, but

   can you use this to surf the web?  We go of course you can.  And she goes to the
                                            28

   Department of Army.  And all of a sudden it popped right up.  That web was

   designed to be compliant with Section 580, another thing you folks need to know.

   When we use voice recognition, it will work together.

        So all of a sudden she pops up and said where in Army?  We use the voice

   and go to her site.  She gets so excited and then gets depressed again.  That's

   fine, but I'm an accountant.  Does this work with spreadsheets if I go back and

   do my job?  We go, sure.  We pulled up Excel and she gets so excited.  She turns

   around and says I'll be able to do the checkbook again.  Thank God because you

   made such a mess of our checking account.  She left walking tall.  She was

   waving her hands.  She was excited.  And she was just feeling so different

   because she saw the power of technology.  She saw there was something more she

   could do than stick a pen in her hand and use the keyboard.  We refer to her as

   our workers' compensation claimant.  We refer to her as our Pentagon survivor.

        9/11.  Second day on the job.  70 percent of her body was burned.  She lost

   her feet, her hands, her body was badly scarred.  She had multiple skin graphs.

   She was in the hospital for a long period of time.  And she remained home for

   awhile until she went back to work because we provided her with telework.

        Telework -- work is what you do, not where you do it.  Because of her bad

   burns, she did not want to be in an environment that would maybe have high

   levels of infections as we can all understand that.

        So we had the ability to set up a work station for her at home.  Rehab

   professionals, think outside the box.  When you have someone who has been

   severely injured, who may be able to work but can't go back and forth to work,

   perhaps telework is a solution.  Know the technology.  Be able to sell to that

   manager all that person needs is a laptop and a web camera and they can do the
                                            29

   job.  Promote it and advocate for it and make sure this can be a potential tool

   for employment.  So those returning service members who may not be able to go

   back and forth or just having too many rough days, they can work, but sometimes

   they just can't be around everybody.

        Make sure you understand the technology.  Make sure you understand what

   needs to happen so someone can telework.  What we do for federal employees is if

   someone has a telework agreement, I pay for the second work station.  I'll pay

   for the second one because to me you don't throw away talented people.  We

   accommodate them.  Anything less than that, we have failed.  So this is how we

   do some of our things for employees with disabilities.  This conference is

   focusing on our veterans.  I'm going to ask this young gentleman to turn so I

   can show you the DVD that was produced by Walter Reed on what we call warrior

   rehab.  A little bit interesting and we'll see your response after it.

   Hopefully you can see it relatively well.

        I'm going to start it.

        In the meantime while he pulls that up, any questions?

             >> AUDIENCE MEMBER:  (Inaudible).

             >> MS. COHEN:  The question was especially at the graduate level is

   there a way in which the colleges can admit the students who have disabling

   conditions.  The bottom line is it's against the law if you don't.  You're

   covered by Section 508.  Know your laws.  You cannot discriminate against people

   with disabilities and they must be able to access any federal program or

   initiative or anything that receives federal grants.  So when even you give

   grants, you must make sure that your grant process is equally accessible to all

   who want to participate.  That is the law.  And you then must accommodate them.
                                            30

   So I hear the music.  Hopefully we'll have the ability to see -- if you hit the

   start button, you can see the DVD.

        (Video Playing).

        (Audio Difficulties).

        (Rap Music Playing On Video -- Audio Not Intelligible).

             >> MS. COHEN:  The men and women at Walter Reed and the other service

   members I have met around the country, first and foremost, they still see

   themselves as warriors.  Our challenge as we start to work with each and every

   one of them as they return is to respect their role as that warrior.  They are

   not ready to be called people with disabilities.

        A couple of years ago, when it was very obvious to me that they were coming

   back in large numbers and they need -- and they had devastating injuries I said

   I need to do something.  So I developed an initiative from deployment to

   employment.  They are going overseas.  They are being put in harm's way.  They

   are coming back with devastating injuries.

        Things are different now than in the past.  The normal demographics of this

   group is their ages are 19 to 21.  They are mostly males.  They are mostly

   private enlisted and they are coming back with a variety of a combination of

   injuries.  The other thing that makes this war different is that this year this

   time the survival rate is about 91 percent.

        My boss, the Assistant Secretary of Defense for Health Affairs that

   overseas all the surgeon generals of the different services and works with them

   all closely says many times if they are alive in theatre, they will come home.

   That's the good news for many of them.  The bad news is they'll come back with

   devastating injuries.  Are we prepared to welcome them home is our challenge and
                                            31

   what I want to address.

        One of the accomplishments is a passing of a new law.  When I was young I

   used to protest laws.  You know how it is.  Now I just change them.  So I

   changed the law that allowed service members to be able to retain the equipment

   I give them while they are in active duty.  It used to be that once you separate

   from active duty, you have to turn everything back in and you start to get

   everything again from the V.A.  I thought that was pretty dumb.  Why do I want

   all this assistive technology back just so the V.A. can get it for them again?

   The taxpayer pays twice and then you have that break of service or wait until

   they get to the V.A. to learn about it.  Also dumb.

        So we just changed the law.  I figured that was easier.  So that's what

   we've done, and last year alone I sold over 3,000 accommodations specifically

   for service members.  It's hard to see the picture, but the young man I'm

   standing next to, I did not know he was that tall, but everyone is next to me.

   I saw him in a chair.  He was so badly burned he was bright pink.  He lost his

   hands.  They were just burned off.  Lost a lot of his legs.  They were burned.

   He was in a burn unit at Brook Army Medical Center for quite awhile.  He's one

   of the users of assistive technology.  When it comes to rehabilitation, one of

   the first things I wanted to do was introduce them to assistive technology.

   Because as a young healthy able-bodied marine, if you're a fighting man, why

   would you know about assistive technology?  You wouldn't.  That's not part of

   your world.  So when they come back, and they look down and they have no hands,

   they start to say now what?  The first thing they always say to me when I meet

   my service members is I want to go back.  I can't do much about that.  The

   second thing they usually say to me is I want to stay in touch with my troops.
                                            32

   That I can help them with.  So we start to introduce them to assistive

   technology.

        We started to do on site needs assessments to see what they would need and

   what they are ready and able to handle.  You never want to introduce more

   technology than they are able to manage or handle because then you will create

   another scenario of failure.

        But you want to introduce it and then sometimes you step back.  One time

   when I introduced -- I had Jaws on.  Because I met this young soldier, his name

   was Sergeant Pepper.  I'm serious.  So I talked to him and I said, do you need

   anything?  He says, no, ma'am.  I stepped back.  So we just had Jaws playing in

   the background.  And he finally turned around because he has no eyes.  He says

   what's that?  I go that's technology that allows a blind person to use their

   computer.  Yeah?  How does it work?  Can you use it for gaming?  And I said I

   wasn't sure how well it works with gaming tools but I thought it was critical

   that he was trying to get engaged.

        By the time we left that day, his wife came over to us, hugged us and

   started crying.  This is the first time I've been able to leave my husband

   because he's got something to do.  Let them know how to use technology as before

   because they were using it beforehand and some not so much.  So those individual

   accommodations and working with the various medical apartments, amputee care, O.

   T., speech pathology and working close with the case managers to get that

   happening.

        Let's go back for a moment, the picture on the top, again, very hard to see

   because the lighting here isn't great, but if you can see the young man with his

   father using a communication board.  He may look vaguely familiar because he was
                                            33

   one of the persons of the week on ABC News.  This young man had lost a leg and

   was going into cardiac arrest, and it took a little bit longer than we would

   have liked to revive him.  So because of that, he had toxic brain injury which

   means he cannot walk, talk, eat, speak.  He cannot use his hands.  It was

   brought to my attention and we quickly got him a communication board.  Once we

   provided that board, we got an E-mail later from his sister who told us about

   the situation, and she says I just want you to know that for the first time

   after eight months he was able to tell his wife I love you.

        When he was on the show, person of the week, it was because he just gave

   the address of the Army's 200th military medical anniversary.  He gave it via

   his communication board.  The power of technology.

        I want to do this quick case study.  We met this gentleman -- hard to see

   this picture.  He's holding one of his twins that were born during his

   deployment.  He's a National Guardsman.  He lost his eyes.  He is now blind.  He

   has very limited use of his hands.  You may be able to see his hands are

   bandaged.  You can also see scars on his head because he had traumatic brain

   injury.  And when he was first addressed -- when we were down there the first

   time happened to be the same time that one of those many T. V. shows are down

   there trying to show the story of the soldier, and we turned to him and said

   what are you going to do now?  He turned to them and he says I don't know.  I

   guess I'll send a card and hope someone will dress and feed me.  Obviously he

   has very good health care providers at the Brook Army Medical Center.  OT, PT,

   doctors, nurses.

        We started to introduce him to assistive technology.  Now, he can't use his

   hands, so we brought Dragon.  So he can't see -- so he can't see what is coming
                                            34

   up on the screen.  That job was Jaws.  We found the technology that connected

   the two.  And all of you in the rehab field need to know it.

        He started to use the technology.  We went a couple of months later and

   said how are you doing?  He said do you know what?  I think I'm going to go back

   to law school.  Wow!  We go really?  Yeah, I found out all the information on

   the web and I can go to law school.  I can go through rehab services and I can

   do this and that.  Now, I could not care less if he goes to law school.  Heaven

   knows we've got enough lawyers.  I cared that he has a vision for the future.  I

   care that he can see himself as a provider for his kids versus his kids taking

   care of him.  I care that he now is at the V.A. rehab center and as V.A.

   professionals say he is light years ahead of the rest of the people at the V. A.

   because he has learned and started using assistive technology so early on they

   did not fall into that pit of I don't know if I can.  I can't do anything.

   What's going to become of me.  I can't see.  I can't use my hands -- da da da.

   But if you rehab professionals don't know the tools, then you can't introduce

   the tools, and if you can't introduce the tools, you can't give them hope.  If

   you can't give them hope, then you might as well ship them away.  You've got to

   work and know the tools.  It's not the only solution, and I know enough to know

   that.  And you don't introduce tools before they are ready to introduce tools.

   You know when to do it and how to introduce it and then you step back.  If you

   don't know what there is out there and you are telling people to put a pen in

   their hand and tape it around, you have failed them.

        Know the tools.  So we're very happy to see that now he is moving quite

   well ahead.

        Transition -- they will be transitioning every single part of the armed
                                            35

   services has this unique program to support their soldiers, sailor, airmen and

   marine, to help them to be reengaged, but once they separate from the active

   duty, they will become the beneficiaries of the V.A. system.  Many of these

   programs will continue with them, some will not.

        That's where you step in and start to do what you need to do.  You need to

   become aware of these programs and how they are working.  You need to help

   connect the dots.  You need -- if you do care about this population, to become

   well educated on the kind of services they get from these programs because they

   are not all inclusive.  They are going to need other things from the V.A., they

   are going to need other things from the voc rehab people.  They are going to

   need to go back to school.  Now every single school and college in this country

   that receives federal funds should have a program on campus for their veterans.

   They should also have a program for their disabled college student they can help

   accommodate.  Know your tools.  Know the programs.  Know the point of contacts.

   Make the connection.

        Because the last thing the service member needs or wants is any pity.  The

   last thing this person needs or wants is another reference and another referral

   that just says, oh, here is somebody else you need to talk to without you

   helping them connect the dots.  That's your job.  Nothing less than that is your

   job.

        Employment -- this is where again we hope you get very well engaged.

   Because in this fine country of ours -- I met some wonderful people yesterday

   and today and the first thing they usually say or ask me is where do you work?

   Because that's how we identify ourselves in this country is what we do.  Where

   do we work?  Who do we work for?  What's your job?  What's your status?  So of
                                            36

   course the ultimate goal is to go back to work.  Whether it's private sector,

   independent, being an entrepreneur, public sector.  The public sector, I'll be

   able to provide accommodations.  If it's private sector, you're going to help

   them get the job.  Know the solution.

        If they are going to start to be entrepreneurs, know about the different

   programs that can give them funding for them to help them establish their

   different types of opportunities.  Know the different programs that are there to

   help place disabled veterans.  Know about the different ways in which disabled

   veterans can get preference.  Understand the different tax credit programs so

   they can be pushed to the front of the line.  Anything less than that, you have

   not done your job as rehab professionals.

        This is your job.  If you believe that that's what you think is good, if

   you believe that it is your role and your passion to help the employment of

   people with disabilities and now our service members, anything less than that,

   you have not done your job.  So learn the tools.  Learn those powerful people

   around you that can make those connections.  Learn the points of contacts in

   Baton Rouge and Louisiana and other places in New Orleans and where ever else

   they may want to go.  If they don't want to stay in this area, they need to move

   somewhere else and know the connections and who to refer them to.  We'll find as

   they come back home, sometimes home doesn't fit anymore.

        I had this young man who went back home.  He felt so incredibly unwelcome.

   He felt he was being stared at because as we may know or not know, while at

   Walter Reed and other wonderful military treatment facilities or other programs,

   they are one of many.  They are not unique.  They don't look funny.  They help

   each other.  They can relate to the stories.  They go back home and people say
                                            37

   how did that happen?  You know, I really hate Bush and I hate the war.  The

   issue is stop looking like that at me.  They come back so they can be with their

   colleagues.  So you may need to help them start their little community, start to

   help to identify with other service members.  When they come see me, most of

   them don't want to talk to me.  It's not because I'm not nice, I can't relate.

   I don't know what it's like to be in theatre.  I don't know what it's like to be

   shot at.  I don't know what it feels like to be injured in such severity, and

   the biggest challenge you all have as rehab professionals, they are not just

   coming home blind or missing a limb, they are missing a couple of limbs.  They

   are missing their eyes.  They have traumatic brain injury.  They have hearing

   loss.  You have to address all of those issues and help them through that maze

   of recovery.  You have a big challenge ahead of you.  You need to know these

   websites.  You need to do your homework.  You need to help them connect the

   dots.

        Do not give them another business card and say call them.  They've had

   enough of that.  This is our website.  I hope you come to our website and learn

   more.  One of the other things we've also done because we know our audience is a

   lot of our information is now in Spanish because a lot of our young men and

   women who are enlisted are also from Spanish backgrounds or Hispanics and they

   will find that a lot of their family members do not speak English.  They may

   speak English, but when they are in a coma, it doesn't help all that much.  So

   they have to have somebody else help them.  We provide our information in

   Spanish.  Are you providing your information in language that they need?  Make

   sure you're truly reaching out and providing that service.

        Here is our website.  Everything I talked about today is on our website so
                                            38

   please come visit us.

        Here are some more resources.  If you plan to work with the federal

   government and you plan to help them place people with disabilities, the first

   thing you want to do is find out if that federal agency has a disability program

   manager because that becomes your new point of contact.  And say may I work with

   you to help identify qualified people to fill your jobs?  Of course you're not

   going to call that person until you know what kind of jobs they have because

   that's your homework.  Do not call busy managers and say do you hire people with

   disabilities and what kind of jobs do you have?  You call them because you're

   the rehab professional and say I know that you have a high turnover in job X.  I

   happen to have some very talented people that can meet that job requirement and

   can come in noncompetitively under Schedule A.  Anything less than that, you're

   not doing your job.  So start to become that advocate for people with

   disabilities.  Some other websites -- are you familiar with Job Accommodations

   Network?  Everybody's hand should be up.  This is a great, great resource.  Toll

   free number.  Rehab professionals, many Ph.D.'s on the other line that can

   answer your questions about the law, the regulations, the policy and procedures.

   They are also for public and private sector.  Great resource.

   Disabilityinfo.gov.  Know that resource.  They break it down into

   transportation, housing, all the different things that you may need to know even

   on veterans initiatives.  Great resources.

        For all of you who do believe you need to be a little smarter and better at

   assistive technology, I encourage you to attend this conference that will be

   here in a couple of weeks.  It will be in Los Angeles, the other L. A., and it

   goes from March 10th to March 15th.  They will have an extensive exhibit
                                            39

   hall of assistive technology, probably the biggest in the country.  If you can't

   do it this year, plan for next year.  If you can't go that far out, attend the

   conference that is always in Orlando in January.  Anything less, then you have

   not served your clients as well as you could.

        As I wrap up, I'm going to close it up and then I'm going to open it to

   questions.  Next slide.  We have a challenge ahead of us.  Our challenge is to

   make sure that we're providing the best quality of service and abilities for our

   young people with disabilities.  Maybe it's for them to work in federal

   government.  Maybe we need to learn how to accommodate that co-worker who

   becomes disabled.  We need to understand the law.  Maybe it is as a rehab

   professional we need to understand the tools and the regulations so we can do a

   better job of making sure we do it.  Maybe we need to resolve to bring home our

   soldiers, our sailors, our airmen, our Marines.  We have this challenge.

        I invite you, I ask you, I challenge you to join me in welcoming them home.

   Thank you very much.

        [APPLAUSE]

             >> AUDIENCE MEMBER:  (Inaudible).

             >> MS. COHEN:  Definitely.  If you go on our website, you'll see

   upcoming events.  The conference just ended so you won't see that anymore, but

   you'll have a list of our conferences.  If you get on our website, you can

   actually join our listserv and you can get the CAP newsletter and everything of

   course is free of charge.  It doesn't matter if you're private or public sector,

   if you're in the university setting.  Our information is free of charge to

   anyone.  I only buy assistive technology for federal employees, but our

   information, a visit to our tech center is free and open to everyone.
                                            40

             >> AUDIENCE MEMBER:  (Inaudible).

             >> MS. COHEN:  It's California State University at Northridge and you

   can look at it.  And I think -- I really can't tell you off the top of my head

   their website, if you go to our home page, under events you'll see the direct

   link to that conference.  I'll be presenting there a full day with the people

   from JAN and we'll be doing a conference.  I'd like to open it to any questions.

   Try to keep everyone on time.

             >> AUDIENCE MEMBER:  (Inaudible).

             >> MS. COHEN:  I'll repeat the question.  She was asking me what about

   federal contractors.  In the federal government, we have outsourced a lot of our

   jobs so we now have a lot of federal contractors doing work in support of

   federal government.  They are covered by the Americans with Disabilities Act and

   Schedule A does not apply, but know your laws.  Section 503 of The

   Rehabilitation Act requires all federal contractors to also have an affirmative

   action program to hire and employ and accommodate employees with disabilities.

   So when they sign a contract to work in support of federal government, they are

   now taking a direct pledge they will do the same level of support on employment

   of people with disabilities, but they don't get their accommodations from CAP.

   They are not covered by the Rehab Act, they are covered by ADA, but they must do

   the same form of action and the Rehab Act language and ADA is identical when it

   comes to nondiscrimination and accommodations.

             >> AUDIENCE MEMBER:  (Inaudible).

             >> MS. COHEN:  There has never been a mandate.  There has always been

   a goal and the goal is to hire at least -- 2 percent of the federal sector to be

   people with disabilities.  Right now, we are barely at 1 percent and the numbers
                                            41

   are going down and when I go and train people in the field, the first thing

   they'll say to me is they don't know where to find them.  I said have you tapped

   into the voc rehab system?  They don't know about Schedule A and they haven't

   been helpful.  Do your job.  Yes, sir.

             >> AUDIENCE MEMBER:  (Inaudible).

             >> MS. COHEN:  The question was with the growing number of people with

   cognitive and TBI's is assistive technology of any use?  And to a great extent,

   yes.  It really again goes back to the baseline of where that person was

   technically beforehand.

        I have a Lieutenant Colonel with a severe TBI who uses his PDA extremely

   well because he had that cognitive skill beforehand.  He's a very different

   person, and the cognitive skills are different, but he had enough of them to use

   that as a good tool.  A lot of people have found it very useful to use some of

   those queuing tools that are available on the computer software.  So again, we

   start -- that's why we start with the needs assessment.  We have sold many of

   them with a PDA because many of them first of all are technical.  If you're in

   the Department of Defense, chances are you have some technical skills.  So they

   have found it very useful if nothing else to remind them to take their medicines

   and remind them about their appointments.  Other people can't remember enough to

   even know where the hell they put it last night, so it's not useful for them.

   So that's where you come in with a needs assessment and try to identify who can

   benefit from assistive technology.  Who are still too much in a learning mode or

   cognitive issues that that's not the appropriate solution.  Other hands?  Yes,

   ma'am.

             >> AUDIENCE MEMBER:  (Inaudible).
                                            42

             >> MS. COHEN:  No, the V.A. does.  The question was does the V.A. have

   a coming home to work program.  Do I provide accommodations for that?  No,

   because it's a V.A. program.  We do provide the accommodations for other

   internships.  The key to where CAP does and does not is if the person is active

   duty.  If the person is still active duty, and they are in one of our programs

   called operational war fighter or some of the barracks programs or initiatives,

   then we provide them, but once they separate, we have a whole department in

   charge of providing that and that's where they step in.  Another question, yes,

   ma'am?

             >> AUDIENCE MEMBER:  (Inaudible).

             >> MS. COHEN:  The question was they noticed in the picture there was

   a young man with his father and how important it is to have the family

   involvement and it's 5,000 percent important.  In the Department of Defense,

   when they are active duty, there is quite a bit of energy put into trying to get

   the family members together.  To stay together and that's why we have the

   wonderful Fisher Houses around the country so they can stay with their service

   member and family member as they go through recovery.  As you can imagine, some

   of them can't afford to stay that long.  Some of them have too many family

   members and they can't stay that long.  So there are quite a few different --

   that's why you need to know about those other programs.  Palace HART tries to

   step in and helps the family more if they are Air Force.  All these programs try

   to make sure the family members are there.  No one, whether a service member or

   not, doesn't recover better when they have their family support around them.  We

   have them and a lot of the people are the ones who call us and say my spouse

   needs this.  My son needs this.  My daughter would benefit from that because
                                            43

   they are still kind of out of it.  So we depend a lot on the family members to

   give us a reality check.

        Because you'll have the service member -- and I'm telling you.  I met this

   service member.  He lost his eye.  He's got a cane and all he wants to do is go

   back.  He can't understand why he can't go back, and his wife just gave birth to

   a child.  He doesn't care.  He wants to go back.  And it's only his wife that

   really tells us where he is really cognitively.  So it's very critical to have

   that family member there.  Some of them are more engaged, and the sadder part of

   them is that some of them are not staying and we are not the mental health

   counselor that has worked with them day in and day out.  We're a small part that

   deals with assistive technology and we know enough to know to bring them in and

   have them part of the discussion.

        I believe that's all the time I have -- we have one more question.  I'm

   sorry.

             >> DR. KUNDU:  Laurel, hello.  We have one question from a resident of

   (inaudible) from San Diego State University.

        In information and handouts from this webcast, I noticed (inaudible).  Have

   there been studies showing (inaudible).  What role has and will V.A. accept

   employment as work options and (inaudible).

             >> MS. COHEN:  I can't really answer that because I'm not with the

   V.A., but the thing is that there are many different programs including the many

   initiatives on the Small Business Administration, V.A. programs, all sorts of

   initiatives that allow people to get some baseline monies to start a small

   business.  The V.A. plays that role.  Once they separate from the active duty,

   they get their benefits, programs, training, education and funding from the
                                            44

   Veterans Administration.  And like I said, I'm not the V.A.  I'm DOD.  So I

   really can't answer that and I'm sorry if you go to the V.A., there is probably

   quite a bit of information there.  I want to thank you all for your attention

   and I hope we will be able to work with you in the future.

             >> DR. KUNDU:  Just about a five minute break and then we'll start.

        Laurel, do you have any other questions?

             >> LAUREL:  No, I'm going to check with Dawn.  Dawn Heinsohn will be

   the one asking the questions.  They go straight to her.

             >> DR. KUNDU:  I have three questions.  I printed it on the computer

   and the right margin was cut off.

             >> LAUREL:  I tell you what, if you want, Madan, Dawn, can read the

   questions, even the ones that we sent in advance.

             >> DR. KUNDU:  Right.

             >> DAWN:  I can.

             >> LAUREL:  If you want to cue Dawn when you're ready, and she'll say

   no questions have come in or if she has some.

             >> DAWN:  And I do have a few.

             >> DR. KUNDU:  For this speaker or the next speaker?

             >> DAWN:  For Ms. Cohen.

             >> DR. KUNDU:  We're on break now for a few minutes.  Go ahead.

             >> LAUREL:  Would it be possible to send those to her after --

             >> DR. KUNDU:  Sure.  It will be no problem.

             >> LAUREL:  Madan, before we break for lunch, if you could let me just

   let the folks know online that those who are right now on RealPlayer need to

   shift to Windows Media Player for the afternoon session.
                                            45

             >> DR. KUNDU:  Okay.  Should I mention or you should mention it?

             >> LAUREL:  Well, you know what, let me check with our headquarters

   there and we might just be able to get our captioner to type it in right now and

   then if you want to mention it -- if you don't mind, Dawn or I can address it

   just before we break for lunch.

             >> DAWN:  And I can print out these questions and have them ready to

   be read whenever you need me to, Madan.

             >> DR. KUNDU:  Okay.  All right.  I will prompt you.

             >> LAUREL:  And Dawn, we'll hold the ones for Ms. Cohen and send those

   to her afterwards.

             >> DR. KUNDU:  Thank you.

             >> LAUREL:  Thanks, Madan.

        (Five-minute Break).

             >> DR. KUNDU:  All right, may I have your attention, please.  Take

   your seats.

        There are plenty of seats in the front.  There is no test.  Don't be

   worried about it.  Just come forward.

        Laurel, we are ready?

             >> LAUREL:  We're good to go, Madan.

             >> DR. KUNDU:  Good morning.  Good morning.

             >> MR. PETE:  My name is Joseph Pete.  I'm a graduate student.  I'm a

   graduating -- second year graduating student in the Department of Rehabilitation

   Studies, and I have the pleasure to introduce our next speaker.

        Our next speaker name is Dr. Darlyne Nemeth.  She currently practices neuro

   and medical psychology in Baton Rouge, Louisiana at The Neuropsychology Center
                                            46

   of Louisiana.  In 1991 Dr. Nemeth designed and implemented a support group

   program for the spouses and family of the U.S. Army 321st management company,

   which had been deployed to Iraq for Desert Storm.  She has extensive experience

   in evaluation and rehabilitation of brain injured patients.  She is a fellow of

   the American Psychological Association, which is clinical neuropsychology.

   Dr. Nemeth was awarded a full doctor of science degree in clinical pharmacology

   in 1999.  She was granted prescriptive authority by the Louisiana State Board of

   Examiners of Psychologists in 2007 and was recently board certified in medical

   psychology.  She is currently serving as vice-president for the World Council of

   Psychotherapy and is a counselor for psychotherapy and some other acronyms I'm

   not familiar with as well as the delegate to the United Nations.  Please join me

   in giving a hand to Dr. Nemeth.

        [APPLAUSE]

             >> DR. NEMETH:  Well, thank you very much.  I might need this down a

   little bit.

        Thank you very much for that wonderful introduction.  And I do hope that

   this information will be useful for all of us as we move forward to help our

   wounded warriors.

        One of the things I do want to say to you all which many of you may not

   realize is now a certain segment of our psychologists in Louisiana have

   prescriptive authority and what's that mean?  That a patient can come to me and

   I can write their scrips for their medicines and what I do typically is I talk

   with their doctor and we agree on what medicines that I will use and then I

   write the prescription that can be filled at any place including the Veterans

   Hospital or outpatient clinics or just regular drug stores, and I send the
                                            47

   doctor, whether it be a primary care physician, a psychiatrist, another

   specialist that information so that they can put it in the patient's chart.

        I cannot tell you what an advance in health care this is, and I'm so proud

   that Louisiana, although it's the second state in the union to have passed

   prescriptive authority, it's the first state in the union to enact it.  In other

   words, you are seeing in front of you a psychologist who is writing

   prescriptions.  The first state was New Mexico, but there it's still bogged down

   in politics.

        Now, this is so important because whether it is a patient that I'm seeing

   privately or a patient that I'm seeing who is a veteran, okay -- I saw a veteran

   yesterday at quarter to 4.  Of course the medicine that he needed he had to take

   that night.  It was not an option that he go without this medicine.  Okay?

        Now, I only prescribe mental health medications, okay?  So no Viagra or

   anything like that, okay?  But anyway, the whole idea is that it would have

   really been a disaster in terms of his mental health issues if he had not taken

   that medicine last night.

        So I was able to give him a prescription even though by the time I finished

   it was four o'clock and the outpatient V.A. clinic pharmacy was closed, he was

   able to go to Rite Aid and get that.  Next time he can go to the V.A. and get it

   refilled.  But the deal is that he did not go without his medication and that's

   really important.

        Now, one of the things that we did when this law was passed for

   psychologists with a (inaudible) in pharmacology to be able to have prescriptive

   authority is that we agreed that we would do it with the primary concern being

   the patient, okay?  For example, with my patient, I do not charge for writing
                                            48

   scrips.  That's part of my service to them.  And even though his appointment was

   last week, even though this week, yesterday, I wrote that prescription, he came

   in.  I took the time.  His cost was zero.  Okay?

        So what we're trying to do with this prescriptive authority also is to keep

   health care costs down.  And it really is working.  Of course one of the things

   that I'm learning is all the pitfalls that all physicians have learned for

   years, which is you just can't write scrips after 12 noon on Friday because the

   only people who seek medicine after 12 noon on Friday are our drug people.  You

   know, and really, you think they would just want addictive medicines.  Oh, no,

   anything.  Because that weekend they'll go out and have these little drug

   parties where you put all the pills in a bowl and everybody takes some.  Have

   you heard of those parties?  So now I really do understand why it is that most

   physicians will not write scrips after 12 noon on Friday.

        I want to introduce to you some special guests that I have here, two of

   whom will bear witness to what I am saying to you and will be available during

   lunch to talk with you about this.  And three of whom help me in the preparation

   of this presentation.  I would like to first have Lieutenant Colonel Retired and

   Mrs. Betty Jean Kramer and George Kramer stand up.  Retired Lieutenant Colonel

   was in active duty -- I believe you were a reservist, but called to active duty

   for Desert Storm.  And although that war was quote-unquote very short, it was I

   think somebody told me 41 days, our military was there for much more than 41

   days.  In fact, I think, George, how long were you there?

             >> AUDIENCE MEMBER:  (Inaudible).

             >> DR. NEMETH:  He was there almost a year.  So this is important to

   recognize and the Lieutenant Colonel's division came from Baton Rouge.  Okay?
                                            49

   So they are our people and we have to know a little bit about how our people are

   being and have been treated.  Okay?

        Of course I would like to see the best for everyone, but as we know,

   sometimes that doesn't always happen even when people are trying very, very

   hard.

        The next group I would like to introduce are my staff, including Traci

   Wimberly, Amity Lewis, and the newest member, Jonathan, okay?  We're trying to

   get Jonathan into the program here so that's why I wanted him to come today.  My

   effort to politic for Jonathan's acceptance into the rehab program.  (Laughter).

        Traci and Amy will be going into doctoral programs in psychology, but I

   would like for him to start out with your program because in my opinion, it's

   fabulous and the best one in the country.  Of course I'm not prejudice at all.

        All right, now, basically, what I want to do is start out -- first, you

   have most of my speech in a handout, so I don't want to follow it just letter

   for letter, but I do want also to acknowledge him even though he's not here,

   John Hamilton.  And John Hamilton is a young man that I have known all of his

   life.  In fact, I am his Godmother, and he is in a doctoral program in

   neuropsychology at the Pacific School -- Professional School of Psychology which

   is the professional school attached to Stanford, okay?  And he has completed

   externships at the V.A. Hospital in Palo Alto and at the V.A. Hospital at

   Livermore.  So my effort here is to bring real live information and then to

   suggest what we can do from there.

        But it's very necessary and it's a missing gap is that we have an

   outpatient treatment program for our wounded warriors and this program really

   needs to focus on two aspects:  One is the rehabilitation of traumatic brain
                                            50

   injury usually caused from blast injuries, okay?  Blast injuries are the big

   deal in this war, okay?  And the second is the posttraumatic stress disorder.

   The two might go hand in hand.  A person might have both.  A person might have

   one or the other, okay, but really it needs to be treated in the same

   comprehensive program.  And it really does need to be a comprehensive program,

   but it's so amazing to me, and I've been doing neuropsych rehabilitation for 30

   years now, this is the least expensive form of rehabilitation there is, okay?

   And yet people don't do it.  This just drives me insane.  Anybody -- I'm going

   to propose a program and hopefully we can write a grant or do whatever we have

   to do to get this to the attention of the V.A. or the Department of Defense.

   I'm not sure about all the politics of it all, okay, but what we're looking at

   is people who have come out of acute care programs, people who have already had

   their therapy, occupational therapy, physical therapy for the most part.  So

   that is really already accomplished.

        Now, I am not so naive as to think that these three modalities will return

   a person to their previous status.  Usually after about six to nine months

   post-trauma, it's going to be as good as it gets.  And then what happens is

   frequently you have to continue this type of intervention to keep people

   functional, okay?

        So I'm not saying, oh, we stop at six or nine months.  I'm not saying that.

   I'm just saying that any kind of outpatient program for TBI, PTSD would really

   focus on people who have already done that other stuff, okay?  Because even

   though we have these fabulous programs that you saw from Dinah's presentation

   that there has to be so much emphasis on the physical aspect of rehabilitation

   that the neurocognitive aspects just kind of sometimes gets put to the side.
                                            51

        Now, that's not terrible because the way the brain is structured, you

   really get the best neurocognitive rehab between nine and 24 months post-trauma.

   So if we take the first six to nine months to do the hard physical, speech,

   occupational therapies, dealing with severe wounds, putting the devices together

   for these individuals that Dinah talked about, we're doing our jobs.  That's

   wonderful.

        But then it's time to restructure the rest, and there is plenty left to

   redo, and that's what I find is missing.  There is a gap there.  A person gets

   out of whatever acute care situation they have been in and then there is this

   huge gap.

        Now, one of the things Dinah said was really wonderful, and that is for all

   of you vocational rehabilitation specialists, you have the tools to know how to

   put these people in touch so that there isn't a gap.  You have all these

   websites, et cetera, et cetera.  Your average person who basically is maybe

   still in the military or is retired military, they have no idea of all these

   things.  Okay?  And so they come home just totally lost, and George and Betty

   Jean, anybody who wants to talk to them about this will verify that, how many

   people even to today's war come home and don't have a clue.  Okay?

        And so they are not getting the help they need because they don't know how

   to access it.  So I just want to kind of use those kind of preliminary

   statements.

        Now, most of you have my abstract and what I want to really focus on in

   that abstract is the second paragraph because this was really a shock to me when

   I actually looked up the difference between what is ethical and what is moral.

   You know I thought for all the years I've been in practice that it was the same
                                            52

   thing?  For me, it is the same thing.

        But that's not true.  Okay?  So I want us to just be aware of the

   difference.  Ethical is conforming to expected standards of conduct.  Moral is

   conforming to the standard of right behavior.  And what I have come to learn in

   dealing with our wounded warriors, regardless of what war it is, is that there

   is a big difference between what is accepted and what is right.  Okay?

        And I think we have to correct that because in my opinion effective

   intervention programs must strive to do what is right, not merely what is

   acceptable.  I mean, just because something is the community standard, which is

   acceptable, doesn't mean that it's correct.  Like, for example, one of the

   things that I see in my practice is a lot of children who have some type of

   attentional problem.  Well, they go to their pediatrician, mom or dad brings

   them, and in five minutes, the pediatrician gives a nice little questionnaire,

   decides it's ADD and puts them on medication.  That's acceptable standard.

   That's not what goes on in my office.

        Okay, I've got to figure out why it is that they have this attentional

   problem.  It's not always ADD.  Okay?  So they go through a rather elaborate

   evaluation process and at the end, you know, we really work hard to determine

   the etiology of the problem so that effective intervention can occur.

        I want to emphasize that to all of you because we are now in a day and age

   of managed care, and as I tell all of my patients, managed care means that you

   have to manage your own care.  The doctor is no longer managing care.  The

   doctor is lucky enough if he or she gets ten minutes with you.  Okay?

        So consequently we have to be very aware and strive here as vocational

   experts to make sure that the person that we are serving gets the right workup.
                                            53

   I cannot tell you how many times -- I've stopped taking managed care.  I just

   can't take it anymore.  It's too sociopathic for me.  I just can't do it.  I

   would rather give free service than to deal with that nonsense, okay?

        And basically what happens is in managed care because one of my colleagues

   in our group takes managed care, they will give him all the time he wants to

   treat the patient.  They will give you no time to evaluate the patient.  Think

   about that.

        Now, that's going to be important when we talk about developing an

   outpatient program for our wounded warriors because what is happening -- and I

   talked with Dinah last night about it.  I know it's happening.  I've got tons of

   information in my speech to tell you, yes, it is happening.  Is that people are

   not taking the time to properly evaluate our wounded warriors.  So consequently

   when you do rehabilitation at a neurocognitive level, you're just shooting in

   the dark.  This is such a waste of time and money when a good assessment of what

   will tell you exactly where the pathways are that have been broken, and exactly

   what you need to do to reconnect the dots.  You know, it's really so cost

   effective, but I cannot prove that to anybody.  In fact, I was telling this lady

   here, she's from the Veterans Administration, and I said I want to talk with you

   before you leave because I got a call from the V.A. on Monday saying Dr. Nemeth

   would you do neuropsych evaluations for our brain injured patients?  I said I

   would be honored to.  They said the reason why we're asking you is because our

   neuropsychologist is ill.  I don't know what happened, but he will be out for

   six months.  Okay, we really need somebody to fill the gap.  I said I am happy

   to do that.  And then the person said -- when I said are you coming to this

   conference?  The person didn't know a thing about this conference.  So right
                                            54

   there I got very nervous, okay?  And then I said, well, hopefully you're sending

   somebody to this conference?  And then once again there was no response.  And I

   said please at least look into it.  You know, let people know about the

   conference because it's really important.

        And then she asked, we pay just a little bit over the Medicare rate for

   neuropsychological evaluation.  Would that be acceptable to you?  And I said you

   need to know that Medicare pays zero for neuropsychological testing.

   (Laughter).

        And two times zero is still zero.  You know, and I will be happy to do this

   for you.  Let's just work out something that's a reasonable price, fair to you

   and fair to me, and I'll do it.  Because I feel so strongly about this issue.

   Okay?  I just have to break even.  I don't have to necessarily make money, but I

   can't lose money.

        I haven't heard from her since.  And my staff will tell you that they try

   very hard to keep me from working for nothing because then they don't get paid,

   so we can't have that.  Okay?

        So again, for anybody here from the V.A., I'm willing to step up, we just

   have to come to terms as to what is a reasonable amount to pay for this service.

   Honestly, as the person who does this for them is unable to do it for the next

   six months, hopefully they'll have some funds available so that we can do this.

        So if we could now, let's just start with some of the basic things, and one

   of the basic things is our abandoned soldiers.  Now, this is another reason why

   I asked Retired Lieutenant Colonel Kramer to be here with us.  Let's not think

   this is a new phenomena.  Okay?  It's been going on forever.  I was able to in

   my research trace it back to -- all the way to the Civil War.  I'm sure it was
                                            55

   going on before then.  It's just probably that's the first time it was really

   documented.

        And what happened in the Civil War is these individuals became known as

   wandering veterans.  They just kind of wandered aimlessly around.

        And then World War I, they got a new name, they were called the bonus army.

   Okay?  And then of course they were called bonus army because they didn't get

   the bonuses that they were promised.

        And then of course Vietnam, there were tens of thousands infamously

   rejected and then forgotten war weary veterans.  We lost the war, and we

   punished them for it like it was their fault somehow.  Okay?  I was young during

   Vietnam.  I lost a fiance in Vietnam.  He was in some kind of special unit.  He

   was doing a spy mission to Cambodia and never came back, and it was just really

   tragic for me.  He said if I survive this mission, you'll get a diamond ring in

   the mail and if I don't, you'll get a Black Star Sapphire.  The Black Star

   Sapphire arrived.  Okay?  So I'm very painfully aware of what happens, and then

   when these individuals come back to be treated by our society -- I mean, we had

   the issue of Agent Orange and how many times were people told that that was

   nonsense until General Westmoreland's son died of Agent Orange, it didn't become

   real.

        So we just have to be aware that we have a very bad history in terms of

   taking care of our wounded warriors.  And now we've got over 1500 Iraq and

   Afghanistan veterans who have been identified by the Department of Veterans

   Affairs -- not by me -- as homeless.  I just don't even know what to say about

   that.  That we have over 1500 veterans from these two wars who are homeless.  I

   mean, that is such a national disgrace, I just can't even think about it.
                                            56

        So there has always been a lengthy gap between coming home and the moments

   of darkness that leave some people behind and that currently are leaving over

   1500 people homeless.  So we need to be aware that this is not a pretty picture

   with Lieutenant Colonel Retired.  He was with the U.S. Army's 321st materials

   management center, and we did provide in the spring of 1991 groups of programs

   for the members of that company.  And Mrs. Kramer helped us to work that out and

   we would meet on the weekend and -- Jean, do you remember where it was?  It was

   close.  We would meet on the weekends and we would work with the families.  We

   would work with the spouses especially.  Now, all this work that was provided in

   terms of intervention work by our group was done pro bono.  It's not like we

   were looking for big contracts or something like that.  We did it because it

   needed to be done.

        And the thing that really upset me is when the powers that be came down to

   have kind of like a goodbye ceremony, I will never forget the fellow turned to

   me -- I don't know -- who was a general or whomever, but some high level, high

   ranking officer and said thank you very much, Dr. Nemeth.  We will take it from

   here.  Being so young and naive in 1991 I believed him.  You know what we'll

   take it from here meant?  No services were provided.  Isn't that correct?

        We'll take it from here meant zero.  Now, we would have been glad to have

   continued the support groups, the reunification groups, all of those things that

   therapists do, but we were told that we weren't needed anymore, and that they

   would take it from there.  Well, they didn't.

        And as a result, what happened is many families fell apart, many returning

   soldiers returned to no jobs.  Okay?  Returned to no position in their families

   because they had been gone so long.  It's not like they had terrible wives, it's
                                            57

   just that the wives had to step up and be the head of the household and the kids

   were not used to the father being around, so the father is just sitting there.

   What am I, chopped liver?  You know, they are passing by asking mom.  Asking

   mom.  Okay, so basically what happened was that no services were provided.  We

   were just expected to get back to work, yet we were gone so long, that most of

   us had been replaced.  It was a time when services were really needed, and

   that's when I interviewed Lieutenant Colonel Kramer.  He said they didn't have

   any services.  They didn't know about going to Louisiana Rehabilitation Services

   or anything.  They had no services, no direction, not even a card in the hand

   about you can see this person or go here and get some help.

        So consequently most marriages ended in divorce.  Some, like the Kramers'

   marriage, endured, okay?  And so we have to take a look that there are three

   primary causes of veterans homelessness -- mental illness, of course, is number

   one.  And in talking with Dinah last night, she said one of the biggest problems

   they have is that there is such a stigma against getting mental health treatment

   that most military will not do it.  Okay?

        If you ask a marine whether he needs mental health treatment, even if he

   has all those limbs off?  He'll say, no, I want to go back and fight.  Mental

   health treatment is still considered a sign of weakness.  Okay, and

   unfortunately one of the big problems with neurocognitive rehabilitation is that

   many of our soldiers see that as mental health treatment.  That is not mental

   health treatment, okay?  It is major neurological treatment, but that's not the

   way it is perceived.

        So one of the things that happened in Vietnam as we know, many Americans

   didn't support the war or the troops, but at least in Iraq we're a little bit
                                            58

   lucky because although many Americans do not support the war, they do support

   the troops.  So we have a break there, and thank God for that.

        So basically what happens is a lot of veterans when they come back, they

   are just expected to become invisible, to slip into the shadow.  Now, in many

   respects, and I know this might sound ludicrous, but if a veteran does have a

   missing limb, okay, at least you know that they've been injured.  So you might

   look at them funny for a little while, but you know that their injury is

   genuine.  Most people with these blast TBI's won't have a missing limb because

   you could get a blast TBI without getting some kind of physical disability to

   accompany it.  Okay?

        And what is really amazing to me is individuals or soldiers who have

   suffered these blast TBI's don't usually come to the attention of any medical

   unit until the third exposure to a blast TBI.  And even then they might not have

   a limb problem or a major medical problem.  So when they get back to this

   country and they go through whatever disengagement process, they say I'm fine.

   I'm fine.  So they get their benefits.  They get retired and they go home and

   then they can't function.  And then somebody writes a diagnosis of psychiatric

   on their chart, when in reality the real diagnosis is blast TBI.  Also what was

   apparent to me as I was putting this speech together is that our polytrauma

   units -- and we have excellent ones.  I mean, now, thank goodness for Bob

   Woodruff.  They cleaned up their act at Walter Reed.  They have an excellent one

   at Palo Alto, and I know because I have an extern there.

        Let me give you real facts.  These units can take 45 people.  And you have

   to be in their program for six months.  Now, by my recent calculations, the

   number of people as of last year who needed TBI acute care was 2,000.  We have
                                            59

   200 available spaces, and a waiting list six months long.

        What's happening to the other people?  Am I the only one who wonders this

   question?  What's happening to the other people?  Because remember what I said

   earlier?  And that is that the best time for a head injury rehabilitation is

   nine to 24 months post-trauma.  That doesn't mean you can't do some good work

   afterwards, but any of you in the active field, you know that is the best time.

   So they are on a waiting list for nine to 24 months?  And then we expect decent

   results?

        So we need to get real folks.  When I put this speech together, I asked

   John Hamilton, I said, John, check this out for me.  Are there only 45 beds at

   the Palo Alto V.A., the best rehabilitation program that the V.A. has?  And he

   said, oh, yes, 45 beds.  And he said a person has to agree to stay for a full

   six months.  Okay?

        Well, what happens if a person is missing their family?  You know, what

   happens is the family can't afford to come up.  Palo Alto is a high priced part

   of the world.  Do we all know that?  It would cost a lot more money to live in

   Palo Alto than it would to live in Baton Rouge.  Many of the veterans just check

   out because the families can't afford for them to be there.  Their families

   can't afford to go up and visit.  Okay, think about our hotel and motel costs

   here in Baton Rouge and double it.  Okay?  And frequently, even though there is

   a tremendous amount of care given to the veteran, it's kind of like where is the

   family program?  And even John said the social workers do a really good job at

   helping when the veteran is released from the program to go to the next level,

   but after that initial contact is done, they are on to the next page.  And so we

   know, all of us in our field, how easy it is for a person to get lost in the
                                            60

   system.  Think about how easy it is for a person with brain injury to get lost,

   okay, because they might not have the cognitive wherewithal.

        Now, I'll tell you, again, I want to point out that these polytrauma units

   are really great for moderate to severe brain injury.  Really do not assess very

   well mild to moderate, and interestingly enough our mild to moderate brain

   injured patients cause a lot more trouble than our moderate to severe brain

   injured patients.  Do we know that?  Do we all have an agreement on that?

        But yet these people are getting no services because they are not even

   identified.  Oh, you were in three TBI blasts?  Well, that's great.  Hey, you

   can walk and talk and make sense, goodbye.  Okay, because they are not being

   identified.

        The programs are not geared to mild to moderate TBI's.  Now, why do I say

   that?  Recently in Baton Rouge and West Baton Rouge Parish we've had two -- no,

   three or four cases of people convicted of some type of murder, okay?  You've

   read about it in the newspaper.  I have it in my notes here.

        This is what I call failure to reintegrate.  Because what's happened is

   that these veterans basically murdered a child or a spouse or both, okay?  And

   in one case, I believe in West Baton Rouge Parish the person was given 25 years

   instead of the death penalty reportedly because he served his country.

        Okay, so we're not giving these people the services they need.  They go off

   half cocked and do something horrible and then we put them in jail for the rest

   of their life.  There is something missing here or am I the only one that thinks

   that?

        Okay, all of the veterans recently that I looked up in newspaper articles

   that have murdered one or more members of their family, all of them were
                                            61

   diagnosed with PTSD.  All of them within the veteran system, but there was no

   understanding in these articles that I wrote of what kind of care that they

   received.

        Now, I know that it's possible to have these two diagnoses, TBI and PTSD

   being mutually exclusive.  What I am trying to tell you is I tend to put them

   together because most people with PTSD, okay, probably have mild to moderate

   brain injury that has gone unrecognized.  Okay?

        If we had had a decent workup to begin with, I catch those people all the

   time.  Frequently they come across as post-concussive disorder.  If you do the

   right stuff, it usually resolves, okay?  But if you don't do the right stuff or

   if you have any kind of preexisting problems -- like I have a patient now with

   preexisting depression, oh, God, it just really hangs on.  And when the doctor

   says, don't worry.  This is going to resolve, and offers no intervention

   programs, makes people crazy.

        They need intervention even though it doesn't appear that they need

   intervention, okay?  This is so important.  So basically recently I learned that

   for anybody who stayed in the -- I think they now call it theatre -- for 100

   days, not continuous, 100 days period, that there is about a 95 percent

   probability that they will have PTSD.  You know, our boys and girls are over

   there more than 100 days.  They might bring them back and forth, but they are

   still over there more than 100 days.  Also, if somebody has had a blast injury,

   it doesn't make any difference if they were directly affected, it could be the

   air pressure.  They could have been a block away and it would still cause at

   least mild traumatic brain injury.  Okay?

        So these are things that we really have to be aware of, and we have to be
                                            62

   much more active if we don't want more of our veterans to end up in jail.

        Now, you might say, but they killed their child.  It's horrible.  I know,

   I'm not making any excuses, but I am willing to offer you an explanation.  Okay?

   And that is that our military who are riding in these trucks and humvees have

   been desensitized to killing children.  Anybody that comes along close to the

   truck or humvee, regardless of age, with a Coke can, the warrior is told to kill

   them -- not to wound them, to kill them.  Okay?  Because the majority of times,

   the Coke can contains one of these explosive devices, these blast bombs.  I

   think they call it IED's.  So it's me or them, you know, and as a society we

   love our children.  For the most part, we want to take care of them and help

   them.  Do you know how hard it is for somebody with high moral standards to see

   a child with a Coke can, not ask questions, and kill them?  Think about it, but

   yet that's what our soldiers are trained to do.  Okay?

        So when they get home, let's just assume that they have posttraumatic

   stress disorder.  I don't know about you, but if I had killed a child, I would

   have acute post traumatic stress disorder for the rest of my life.  It's one

   thing to kill somebody who obviously has a gun and is trying to shoot you, but

   another thing to kill a child who looks like he is trying to give you a

   Coca-Cola can.  So they come back and let's say something goes wrong in their

   family.  How easy it is to pick up a gun, how easy it is to pick up a knife --

   how easy is it to just hit a person.  I mean, all these people are very strong.

   They have learned and trained to be strong even if they have wounds.  Okay?

        And is there any desensitization process for them?  You see, to me, anybody

   who has had to kill anybody needs a desensitization experience.  I don't care

   how old they are.  Anybody in the line of duty, whether it's a policeman or
                                            63

   whomever, needs a desensitization experience.  It's not like it's on TV and the

   person gets up the next day and goes and performs in another show, you know.

   This is real.  This is dead.  This is forever.  Okay?  So they need that

   desensitization experience whether -- where they can be really talked down.

   Okay?

        Right now I'm just finishing up therapy with a woman who was working in a

   grocery store, nicest lady you'd ever want to meet.  Her co-worker was just

   sweeping up, okay?  She's like 45, 50.  He's 17.  Two idiots come in, drug

   addicts, and decide that they are going to rob the store.  So they start out

   robbing a country grocery store -- I mean, it's not like Albertson's that has

   money.  They start out robbing a country grocery store at 5 in the morning,

   killing the young boy.  Okay, then she has enough wherewithal to have put her

   hands above her head and so the bullets went into her arms and she survived.

        I cannot tell you how long it has taken me to get her through this PTSD.

   Okay?  If I say three or four years, that would be accurate.  What kind of

   desensitization are we doing for our wounded warriors?  Do they have an active

   program?  The veteran whose scrip I refilled yesterday, I said to him, you know,

   you really need to get into an anger management group.  You told me -- this is a

   guy who does not lie, okay?  He might go off, he might hit you, but he doesn't

   lie, okay?  I said you told me that you were going to do this.  He said I signed

   up for it.  I went over for it, and they told me that the psychologist who was

   running the program had to cancel the program.  Okay.  Well, I don't have a good

   therapy experience for veterans who have anger management problems, and as you

   know from what Dinah said, it's very crucial that -- it doesn't have to be that

   the therapist be a veteran and has been in war, but there has to be other
                                            64

   veterans, other soldiers in the group to make it real.  Because they are going

   to look at me and say, well, blonde hair, blue eyes, what do you know?  But

   they'll look at each other and nod, you were there.  You know.

        I remember a number of years ago when I was just a young psychologist and

   in the '70's at the L. S. U. student health service, for some reason or other,

   at the MCAA, the athletic organization, decided that they were going to appoint

   a psychologist to be a counselor for the student-athletes.

        Okay, McClendon was the coach at that time, and so he had a rule, if you

   made three offensive, offside penalties in one game, you got to go see Nemeth.

   Now, the players were all excited.  They thought they were going to see Broadway

   Joe and they walked in my office and these are huge boys, okay, you know,

   African American, Hispanic, Caucasian, any kind of variety, huge boys,

   300 pounds at least.

        They walk into my office and they say where is Broadway Joe?  I said I'm

   Dr. Nemeth.  You're Dr. Nemeth?  Yes.  And I don't think I want to be here.  You

   don't know anything about football.  I said, well, that's true, I don't know

   very much, but I'm the one who decides if you play next week.  Oh, immediate

   cooperation.  And many of those young men -- of course I can't tell you who --

   went on to excellent professional careers, made lots of money, and they would

   call me every now and then, Doc, what do you think I should do about this, that

   or the other thing?  And I would say, you know, you've got psychologists there

   making six figure incomes.  Why do you want to ask me?  And they said, I'm not

   interested in what they have to say.  I want to know what you have to say.

   What's that all about?  We had a track record.  It didn't matter that I didn't

   play football.  It mattered that I knew what I was doing and could facilitate
                                            65

   their work.  Okay?

        That's what we need here.  When we develop this program, this outpatient

   program, it doesn't matter if I or other members of the team have been there,

   what matters is that we know what we're doing and that we can put the veterans

   or wounded warriors together to move through this program.

        Now, basically one of the things I also want to talk about is -- you know,

   we can do things when famous people are involved.  And I'm really glad that Bob

   Woodruff -- I hate to say this -- had a brain injury, okay?  Because we needed

   somebody famous, okay, to bring light to the problem.  If it had just been you

   or me, nobody would have paid attention, okay?  But he was a huge, national war

   correspondent, and of course what happened?  He got the best care possible, and

   he returned to his job.  Maybe not 100 percent, but he returned to his job in

   six months.  He had a severe TBI blast injury, you know that -- everybody knows

   that.

        I just want to point this out.  It's not bragging, it's just a fact.  I can

   return any mild to moderate -- not totally severe -- but mild to moderate brain

   injured person back to functionality within six months.  That's my track record.

   Okay?

        People come from all over for me to help them with it.  I don't even know

   how they find me, okay?  I had recently an oil company executive who was making

   more money than I had ever dreamed to make, and he found me because he had a

   subarachnoid hemorrhage.  He wanted to go back to his job.  He was told by his

   neuropsychologist, et cetera, that, no, you just need disability.  He said I'm

   not going on disability.  I'm going back to work.  Somehow he found me.  Six

   months later, he's back on the job at his super duper income and so happy.  It
                                            66

   can be done.  And it's not that expensive.

        I think the total rehabilitation costs for my work with this man was less

   than $5,000.  Think about that.  Less than $5,000 for returning a person to

   functionality.

        Now, of course, we heard a lot about the various bills that were passed and

   how things can be altered and I'm so glad that Dinah is in a position where she

   can do this.  I have no political connections whatsoever, okay?  And I tend to

   say the wrong things, so I'm not always politically correct and people don't

   always like what I'm saying, but somebody has to say it, and so I've chosen that

   role.  But we've had so many bills -- okay, look at all these bills.  It almost

   makes me sick.  Because none of these bills have been enacted into law.  They

   maybe have gone through the Senate and the House, but they haven't been signed,

   and you know if it's not signed, it's not law, and then if it has been signed,

   it's not funded.  So all of this is well meaning.  I urge you to look at it.

        Traumatic brain injury, health enhancement and long term support act and on

   and on and on, and Senate Bill 1349, Military and Veterans Traumatic Brain

   Injury Treatment Act.  I was looking at that thinking, boy, if we would put

   together a grant, maybe we could do it under this act, and you know, we talked

   with people and they said funds aren't available until next year.

        Okay, so our veterans are going to wait another 12 months for this type of

   care just because we can't get through the politics?  I mean, this is just

   ridiculous.  It's ridiculous.

        So anyway, that act I thought was really good because the purpose of it was

   to improve the screening, diagnosis and treatment of TBI, to improve

   rehabilitation services for veterans, to improve the best practice of those
                                            67

   things, to identify ways to prevent or ameliorate secondary effects from brain

   injury.  The secondary effects are crucial.  Now if a person can't control their

   anger, if a person can't pay attention, if a person hits their spouse, these are

   all secondary effects.  And people say, well, it's just because they've been in

   the war.  No, usually they have some type of brain injury that has been

   undiagnosed, unrecognized, okay, and these secondary effects are going to hurt

   our society.  They already have hurt four families that I know of just in our

   area, let alone more that we don't know about.

        So we have to understand that there is the advantage of privilege and maybe

   we here in Louisiana aren't so lucky in that because we don't have a Bob

   Woodruff.  We don't have a general's son, okay?  We just have normal people.

        And so we need to do a grassroots effort to bring this about.  The barriers

   to care are just so immense that it's just absolutely shocking.  I'm just happy

   to see the work that Dinah is doing with all the assistive devices, but from

   what I have learned, the barriers are just enormous, okay?

        Frequently soldiers sign away their rights and go into retired status

   without even realizing what they've done or their families do so without

   realizing what they've done.  If they don't really make enough progress during

   their acute care, they're just put in nursing homes.  Okay, they are not put in

   rehab centers that could continue the work and find other methods.  You know,

   that's really important.  So you know that.  I don't have to go through that,

   but it's just so shocking.  One of the boys that Bob Woodruff talks about had

   excellent care at Walter Reed.  Then he went home to Texas, and he lives

   200 miles from the nearest outpatient V.A. clinic.  How can he get there?  He's

   a very young boy.  You know, the average age of the TBI wounded warrior from
                                            68

   these wars is 19.  Do you know that?  Okay?

        Now, here he is, young wife, young baby, very poor, 200 miles away from

   anyplace.  They don't even know about getting an assistive device so he can

   check in on the T. V. or the radio or whatnot, whatever it is that those

   assistive devices do, which I'm all in favor of, but if people don't know about

   it, what are they doing?  Just having an assistive device in a box somewhere,

   you know, as Dinah was pointing out is no good.  We have to be using them, but

   if they don't even know that they are available, okay?  You know, we have a real

   problem here.

        And then I'm just so moved by the man whose son had a severe TBI.  I think

   the boy was maybe 22, and right before his TBI, this was Sergeant Eric

   Edmundson.  He called his dad and dad was terribly worried.  He said, don't

   worry about me, because if anything happens, the Army will take care of me.

   Okay.

        Well, you know at lunch Lieutenant Colonel Kramer and his wife can tell you

   more about that.  So anyway, one of the things that maybe we'll be talking about

   this afternoon is the importance of using private resources like the

   Rehabilitation Institute of Chicago, many private resources have offered help,

   but you know, those resources have been rejected.  It's just like us with

   Katrina, look how many private resources offered help.  Oh, my gosh.  They were

   rejected over and over again because it wasn't protocol.  You know, you didn't

   fill out the right form.  You didn't do this right.  You didn't do that right.

        My good friend, Evelyn Hayes who is an Ob/Gyn in Baton Rouge was here at

   your basketball arena when it was set up as a field hospital.  And I can't tell

   you what she went through to prevent the Red Cross from feeding the diabetes
                                            69

   people honey buns every day.  It took her three weeks, and she was a volunteer.

   She gave up her practice to come here and to be in charge of this work, okay?

   Did anybody ask her?  No.  Did she do it?  Yes.  And all she had to do was spend

   half of her time gatekeeping and keeping people away from making a mess.  Okay?

        So just remember that we just have to be aware that this is going on.

   Another thing we need to be aware of is that, yes, gains have been made, but you

   can read in my outline what Mr. Hamilton says about his V.A. experiences, the

   Palo Alto V. A. is the best of the best, and it is doing work for 45 people at

   the time.  And the Livermore V.A. basically is only for screening, and the

   majority of people at Livermore are old.  Okay?

        And what he said in his experiences at Livermore and at Palo Alto is there

   is almost no room for our young wounded warriors because Livermore -- the

   average age of the patient in that hospital is 55 years of age and older.  All

   they do there is screenings, and most of the veterans won't come for screenings

   because -- especially if they are Marines.  I don't have anything wrong with me.

   I want to go back to the front.  You heard what Dinah said.  I want to go back.

   I want to go back.  They are so trained in that way.  Now, I'm glad because of

   their loyalty, but on the other hand, you know, it's costing them their health.

        Now, let's just quickly take a look at blast-related TBI's.  We have

   primary, secondary and tertiary.  Okay?  And most of our boys and girls are

   experiencing primary TBI's, which is just atmospheric pressure problems, okay?

   And again, remember I said that it takes about three times -- three

   blast-related TBI's before they themselves recognize, let alone somebody in the

   medical team, that they have had a brain injury.  So let's be aware.

        You probably in your -- I don't have it in my notes -- but in your handout
                                            70

   I put a copy of what the brains look like of these blast-related TBI's.

   Unfortunately I didn't have the ability to do it in color.  As my staff will

   tell you, I'm computer challenged.  Okay?

        But if you would just look at any of the dark areas, that's where the

   injuries are.  And the injuries don't show up on CAT scans.  If we're lucky, we

   might catch it on an MRI, but we're not going to catch it on any other things

   and MRI's are terribly expensive.  It's just better to make that diagnosis from

   neuropsychological testing and what a person can and cannot do.  We'll be in

   much better shape if we do that.

        So one of the things that we have to do -- and I think Dinah touched on

   this a little bit -- is we have to make the veteran, the wounded warrior an

   equal part of the health care team because if they don't perceive themselves as

   being able to make a decision about their own lives, they are not going to

   cooperate.  Okay?  And this can be done even with seriously brain injured

   patients.

        You know, when I put somebody on medication, I say here are the facts.  Go

   home.  Think about it.  Look everything you can up on the Internet and then come

   back next week and we'll agree on what we're going to do.  Okay?  I don't just

   say this is what you have to have because frequently it's not necessarily the

   right thing, you know?  And you have to really understand the person.  You have

   to understand their history.

        I want to go through the program that I'm outlining for you on outpatient

   neurocognitive rehab.  You can read most of it.  My staff has done a really

   great job of outlining my notes for you.  The most important thing I want to

   tell you about it is that it's cheap.  We're not talking about a lot of money
                                            71

   here to save these boys and girls.  It's so not in the league with all those

   assistive devices which are so expensive.  Neurocognitive rehab is cheap, and it

   works if you make it real.  If it's not real, it doesn't work.

        I'm going to give you just a simple understanding of how I make it real.

   All the rehab techniques I use, and you know all my neuropsychology friends

   laugh at me, okay, but I don't buy the expensive computer programs, and I don't

   have somebody there figuring out things on a computer.  They can do that at home

   if they know how to use a computer.  They don't need me to be there while they

   are working on a computer.  Okay?  Somebody at a less expensive level than me

   can teach them that.

        What I do is I try to find out what their world is like, and then all

   rehabilitation interventions are consistent with their world.  And I have found

   one of the best interventions possible, and that is Sunday comics.  Okay?  This

   is really important.  One of the tests on the average IQ test is called picture

   arrangement where you're given a whole bunch of pictures, and you're asked to

   put them in order so that those pictures make sense.  Okay?

        Well, golly, the best way to do that is the Sunday comics.  So we give them

   all these little pictures and we say put it together so that it makes sense to

   you.  Okay?  And then they have to do that without using words because I want

   this to be a right hemisphere task, okay?

        And so then after they put it together, then what I do is I put the strip

   in front of them and say, okay, let's see what's the same and what's different?

   And then I hear their reasoning and then they hear my reasoning.  Okay?  And

   then we might do another one very similar to this, but they talk themselves

   through it, and what they find out very quickly is -- and I don't mean offense
                                            72

   to the speech therapists here -- but talking themselves through the test

   actually slows down their brain functions.  Okay?

        And so basically I have to say, okay, let's go back to things we should be

   doing without words.  Why is this important?  You'd say what relevance does that

   have in the world?  Do you realize that most of the things we do as adults are

   without words?  I mean, driving -- how many words are involved in driving?  Most

   of the things are done without words.  And so that just gives you one example.

        So then I find out what the person's life is like.  My latest patient fell

   off a horse.  He's a cattleman.  Do you think I'm going to put him in front of a

   fancy computer program?  He's an outdoor guy.  No, we're going to come up with

   techniques that are part of his world, not that are a part of my world.  Okay?

   That's the most important concept that I want to get across in this lecture, and

   that is effective neurocognitive rehabilitation is not that expensive, okay?

   And that if it is done in a nonprogramed way, but is done being patient

   specific, okay, but yet we involve the family, we involve other wounded

   warriors, the person will get better faster.

        And then the other thing I want to say is education.  All of us who are in

   this room are used to school.  I don't know about you, but I have five degrees.

   I'm not even sure how I got them, okay?  I'm not a good student, okay?  I really

   am not, but somehow I have them.  So I know about going to class.  I know about

   teaching.  I know about those kinds of things.

        Now, I'm not the average wounded warrior.  This is not the profile of the

   average wounded warrior.  The average wounded warrior was lucky if he or she

   completed high school.  They usually have some kind of learning disability or

   ADD or something else that was hidden from the military so that they could get
                                            73

   accepted, okay, and they are no good in a classroom.  So what do we do with our

   rehab programs, especially our neurocognitive rehab programs?  We make it

   classroom-based, something they weren't good at to begin with.  And we sit them

   down in little rows like you all are, and we give them PowerPoint and we give

   them stuff to read -- most of them couldn't read very well to begin with.  Okay?

   It's very important that these interventions be group-based, be picture-based,

   be nonverbal, that any verbalization is paired with a picture.

        I call this the Taco Bell approach -- no offense to Taco Bell, but they

   really do it right, and that is when they train new employees, 80 percent of the

   time, those people can't speak English and so they do it all with pictures.  And

   so, therefore, they have a wonderful workforce.  Maybe not always, but you know

   they do.

        So what I want you to do is see that I put all of these things in this

   rehabilitation program.  I want to talk now just one moment about the single

   thing that keeps -- that causes rehabilitation failure.  And this is my

   experience and I really -- it's on outpatient neurocognitive rehab failures.

   First of all, it's lack of resources.  We all know that.  We're sitting here

   knowing that.

        Second of all, you might not know this -- it is personality disorder.

   Okay?  I can fix any act with one problem or ameliorate it.  (inaudible) are

   another story.  Any patient that I have worked with in neurocognitive rehab, the

   number one reason why they have failed is that they have a character disorder.

   Narcists, don't do well in rehab.  Okay?  On the other hand, I should have put a

   classic C disorder, give me the compulsive disorders.  In general, that is the

   case.
                                            74

        So I want to conclude because you can read all of the things I've outlined

   in it very thoroughly.  You have all those slides.  I want to just put this

   conclusion together for you.

        Effective TBI recovery takes years to accomplish -- not days, not weeks,

   not months, okay, but years.  Our V.A. hospitals are designed and equipped to

   offer brief screenings and acute care programs for six months or less.  V.A.

   chronic care programs are typically filled with the elderly.  During the V.A.

   acute care program, you have speech therapy, occupational therapy, and physical

   therapy that has to come first.  Medical care has to come first.  There is often

   simply no room for our young TBI soldiers returning from the wars in Iraq and

   Afghanistan.  Many of these wounded warriors with especially mild to moderate

   TBI's are just simply slipping through the cracks.  The severe TBI's are often

   unignorable.  If you're in a coma, people can't ignore that.  After six months,

   people find them in nursing homes.  They give up on them.

        We must address this tragic loss of care for those who gave the most for

   their country.  They gave their youth, and their valor and their futures are in

   our hands.  How will we be judged?  Will we be like those who shamed the

   veterans of the Vietnam War and denied them treatment for what many concluded to

   be a fake illness, namely Agent Orange?  Or will we be like those who denied the

   reality of the Desert Storm illnesses that were from the flea collars that were

   put around our veterans and also the anthrax shots that everybody was forced to

   take whether they wanted to or not, okay?  Until proof of their existence was

   published in JAMA, the Journal of American Medical Association and other

   journals and do you know who funded this research because the government

   wouldn't?  They wouldn't fund anybody who wanted to work on this?  Ross Perot.
                                            75

   The funny little man with the funny little voice, he funded the research for all

   of it.

        So will we deny these young wounded warriors treatment for their

   blast-related TBI's and PTSD's?  Will we call them fakers or just behavior

   disorders?  Will we ignore the PTSD's until they explode into violence and then

   just simply put them in prison until they live out the rest of their days?  Is

   this the fate of those primarily 19-year-old boys and girls, who gave their best

   for their country for all of us?  Today, we have to stand up and be accountable.

   Are we going to do what is moral or merely ethical?  Said differently, are we

   going to do what is right or merely what is acceptable?  The burden of this

   national disgrace -- and it is a national disgrace -- is on our shoulders,

   especially us as rehabilitation counselors.

        Many congressional bills have died in committee, others remain unsigned

   into law or unfunded.  There is always some reason why we can't get the money to

   help these people.  This is ridiculous with all the money we have.  Will the

   politics of power and control prevail once again or will we have the courage to

   do what is morally correct?

        We asked these TBI wounded warriors to demonstrate valor on the

   battlefield.  They did.  We must now ask them to demonstrate courage in their

   acute rehabilitation program.  I'm confident that when they feel a sense of

   inclusion, they will.  But will we now demonstrate that same level of courage,

   enough courage to take the necessary steps to create meaningful outpatient

   rehabilitation programs for our wounded warriors?

        I tell you, I have little understanding of how to find my way through the

   quagmire of grass proposals and budgets.  I will leave that to Dr. Kundu.  Okay?
                                            76

   I don't know anything about it.  He's good at it.  So is Dr. Alo.  But I do know

   how to find my way through the quagmire of damaged brains.  I can fix any

   damaged brain in six months.  In partnership with those brain injured patients

   whom I have had the privilege of working with over the past 30 years, much has

   been accomplished.  Most have either returned to work or to productive lives

   within their own families, but now I need your help with a competent team and a

   strong sense of purpose, I know that we can write grants and develop the

   programs necessary to establish outpatient clinics in order to complete the

   TBI/PTSD recovery process for our wounded warriors, as I am confident that this

   can be accomplished in a cost effective manner.  I want to tell you that they

   kept us safe, now we must keep them safe for that is our moral responsibility.

   Let's make their American dreams come true, and let's remember the words of

   Sergeant Eric Edmundson.  Don't worry, because if anything happens to me, the

   Army will take care of me.  Thank you.

        [APPLAUSE]

             >> DR. NEMETH:  How about if we have any questions, we do that during

   lunch?  I'll be happy to answer them.

             >> DR. KUNDU:  Do you have any questions right now?  I know that we

   have a lot of questions from the webcast and podcast.  There are too many and

   we've decided to E-mail them to the presenters.

        Laurel, do you have any parting ones right away or Dawn?

             >> DAWN:  I do have some.  I wanted to -- this first one -- can you

   speak to the unique problems that the fact that the most common disability of

   this war is TBI presents to counselors and employers?

             >> DR. NEMETH:  Yes, I can.  And we do know that that is the most
                                            77

   common and that's the signature wound of this war.

        The problem is that it frequently doesn't show, okay?  If a person has a

   physical disability, it shows and employers and counselors basically know what

   to do.  But oftentimes we don't know what to do with the TBI problem of fatigue,

   aggression, irritability, cognitive confusion, inattention, and we have to make

   sure that those people who are suffering this are in active programs and on

   appropriate medication, that they are not over medicated or under medicated,

   because if they are in active intervention programs and on appropriate

   medication, they can function in the work environment.

        [APPLAUSE]

             >> DR. KUNDU:  Okay, thank you.  I would like you to give the previous

   presenter and Dr. Nemeth -- because we need this evaluation.  So please submit

   it at the table in the back and we'll break for lunch.  And in the back of your

   name tag it says lunch.

             >> LAUREL:  Madan, a quick word for the people on the web.

        For those of you who are participating on the web -- and Madan, we are

   running about 130 people.  Those of you who are using RealPlayer, you need to --

   we're going to switch everyone to Windows Media Player for the afternoon

   session.  We have limitations with numbers of who can be on at one time.  We'll

   switch to Media Player where we don't have those limitations.  We'll disengage

   RealPlayer and when you get back on --

             >> DR. KUNDU:  We'll start exactly at one o'clock.

             >> LAUREL:  At one o'clock exactly.  Thank you, Madan.

             >> DAWN:  This is Dawn.  I'd like to also remind people that the

   PowerPoint presentations are not being played out over the web.  That people do
                                            78

   need to download those and have them on their computer or just open them up that

   they will be looking at those on their own.  They are not being pushed on the

   webcast.

             >> DR. KUNDU:  All right.  Thank you.  All right, bye.



        (lunch break -- return at 1:00 p.m.)



        Chi Sigma Iota -- Initiative Ceremony.

             >> DR. KUNDU:  Ladies and gentlemen, very good lunch, right?  Time for

   siesta, right?  No Siesta.

        Well, we are assembled here to celebrate an auspicious occasion, the

   initiation ceremony of the sigma epsilon chapter of Chi Sigma Iota.  The purpose

   of the society is to promote scholarship, research, professionalism, and

   excellence in counseling and to recognize high attainment in the pursuit of

   academic excellence in counseling.

        The students we have gathered here to recognize these students in

   counseling are the future leaders in the field.  We recognize the committed and

   dedicated professionals in counseling and to develop a network of students,

   faculty and professionals in leadership who will help the future of our

   profession.  They interact, share and exchange information to be up to date with

   the latest information.

        The membership of the society makes a career commitment of excellence in

   counseling.  We all feel commitment to our profession.  So this is the

   20th workshop, and we'll have many more in the future so that we can continue

   to push forward our profession.
                                            79

        The honor society can play a significant role in mobilizing the resources

   in counseling fields and giving a sense of unity amongst counseling

   professionals in pursuit of excellence and can play a role model for others.

        So my question is, who are we?  We are counselors.  You are in a unique

   profession.  We are in a profession to help enrich life.  We are the people who

   make a difference in life.  We give hope to others and give hope to ourselves.

   We are the profession in the dignity of human beings.  You are here for anyone

   who needs help.

        I request the president of the chapter, Susan Flowers to come forward to do

   the initiation ceremony.

             >> MS. FLOWERS:  Good afternoon, everybody.  We are the counseling

   academic society.  We are maintaining high standards of professional competence

   and service.  Our goal is to serve others to the best of our ability and to

   encourage others to do the same as members of the society have distinguished

   themselves through scholarship and professional excellence.

        This occasion of inviting new members into the society who share the same

   commitment and goals, we welcome them in this opportunity to recognize their

   achievements to earn this goal.

             >> DR. KUNDU:  Being members in the society will have special meaning

   to each of you.  The following candidate applications have been reviewed and

   enacted on favorably by the office of Chi Sigma Iota and step forward as your

   name is called.  We are pleased to present the candidates worthy of membership

   in this chapter of the International Honor Society.  Would you please stand.

        >> Membership in the society will have a special meaning for each of you.

   The common meaning, however, will be the same.  You are dedicating yourself to
                                            80

   continued excellence in both scholarship and counseling practice.  As such, you

   ascribe to a higher standard of performance in all that you do.

        On this occasion, you're asked to purposely declare your commitment in

   striving for high standards in scholarship and clinical practice.  If you accept

   the right and the responsibilities of membership embodied by the bylaws of the

   society, please answer I will.

        Further, you are asked if you are willing to continue to encourage

   excellence in the professional settings in which you work.  If so, answer aye.

        Finally, you are asked if you will support and encourage the members and

   activities of this chapter and society through involvement in the professional

   program.  If so, answer I am.

        Congratulations and welcome to Chi Sigma Iota Academic and Professional

   Honor Society.  As your name is called, please step forward to receive your

   membership certificate.

        >> DR. KUNDU:  Now you have joined the membership of 56,682 professionals

   in 251 chapters in the U.S. and abroad.

        (Awardees are being called).

        >> DR. KUNDU:  In a few minutes, the students will receive a certificate

   and pin.

        Thank you.  Congratulations.

        [APPLAUSE]

             >> UNIDENTIFIED SPEAKER:    Good afternoon.  We're all wide awake,

   right?  Let's do some calisthenics before we start the next presentation.  I

   have the honor to introduce the next speaker to you guys.

        Dr. James Malec is a research director of the Rehabilitation Hospital of
                                            81

   Indiana, professor emeritus as of January 2008, Mayo Clinic.  Board certified

   (inaudible) psychologist, through the American Board of Professional

   Psychologists.

        He's active in a professional group and concerned with all people with

   disabilities, the American Congress of Rehabilitation Medicine and International

   Neuropsychological Society.

        He received a number of professional recognitions.  He has over 100

   peer-reviewed publications as well as other professional publications and

   continues to conduct research in brain injury rehabilitation.

        Ladies and gentlemen, I give to you Dr. James Malec.

        [APPLAUSE]

             >> DR. MALEC:  It is wonderful to be here in Louisiana.  The food is

   great and the weather is almost as good.  I moved recently to Indianapolis as

   you just heard expecting warmer weather, but no luck so far.  It is nice to be

   down in the south.

        Professor emeritus really sounds old, doesn't it?  (Laughter).

        That's because it is.  Whoa!  (Microphone feedback).

        The topic that I have before me is evidence-based practice and ethical

   considerations in TBI and polytrauma.  We can move to the first slide.  Much of

   what I have to share with you this afternoon is summed up in this simple figure.

        I'm guessing that some of you may not be familiar with evidence -- or at

   least not intimately familiar with Evidence-Based Medicine.  Can I see a show of

   hands of people who are and who know the methodology?  We have a few.  That's

   good.

        I'll give you a brief overview and more details as we go along, although
                                            82

   the talk this afternoon is not going to be about evidence-based methodology.

   That will put you all to sleep for sure, on top of our wonderful lunch.

        Evidence-Based Medicine is something that developed in primary care and has

   really caught on in medicine generally, and I think more recently in the last

   five or ten years has caught on in the behavioral sciences as well.  It's a

   methodology that allows us to weigh the scientific evidence to support an

   intervention or that supports intervention and that way evaluates the validity

   of that intervention.

        While in and of itself, that sounds like a very good thing.  Like any

   powerful tool, it comes with its risks, and I'll describe those in more detail,

   but I think at this point in time there certainly are two camps -- two extreme

   camps at least.  One who would say practitioners, whether medical or not, should

   not engage in any practices that do not have secure, scientific validation on

   one extreme.  That it's improper to provide services that are not scientifically

   validated.

        Now, the other extreme you find people who say that's nonsense, and

   basically when people come to us for help, we've got to do whatever we can to

   help them out.  Kind of the whatever it takes model of service.

        Like a physician friend of mine who works in the emergency room at Mayo

   used to say when people came into the emergency room with a problem, it becomes

   our problem.  And it really doesn't matter whether they are insured or drunk or

   just wandered in off the streets, we have to help them out of the emergency room

   in the most positive way possible.

        I think in the talk this afternoon what I'm going to try to do is steer a

   middle path.  Certainly there are some real benefits to an evidence-based
                                            83

   approach.  Certainly there is a good deal of validity towards wanting to help

   people and doing whatever we can to help people.  So I'm going to try to balance

   those two from an ethical perspective.

        If we can move to the next slide.  Let me tell you a little bit about what

   may be the strengths of computing systems.  (Laughter)  Okay, you've got the

   handouts.  I think the people on the web have the handout, too.

        Most importantly, an evidence-based methodology allows us to evaluate the

   scientific validity of a procedure.  And you know I think it probably goes

   without saying that that's important.  There is such a thing as snake oil.

   There are people who provide services, you know, either intentionally or

   unintentionally that do no good, and so I think all of us have questions about

   does this really work and what is the evidence to support that proposition that

   it works?

        Certainly with medications, it's a well established tradition that the

   pharmacological substances that we use should be validated against placebo and

   shown to do more good than a sugar pill.  There are some risks to that, too.

   I'll get into that in a minute.

        That is probably the biggest benefit of an evidence-based methodology.

   I've been involved in evidence-based research for a number of years.  I continue

   to be involved with the American Congress of Rehabilitation Medicine group,

   Cicerone.  I think that's very worthwhile, but not without its risks.

        Evidence-based methodology, the quality of the scientific support for our

   procedure is very explicit:  At the core of this methodology is reviewing

   studies and evaluating what is the level of evidence.  Now, in this methodology,

   the highest level of evidence would be a randomized control trial.  So people
                                            84

   without bias are referred to one treatment or control group.  Again, I think

   this is all familiar to you what a randomized control trial is.  And a blinding

   of both the participant and the provider in order to evaluate how effective this

   treatment is without nonspecific effects.  That would be the highest level of

   evidence.

        The second highest -- the second level of evidence would be a controlled

   study that may not be quite as rigorously controlled.  So looking at the effect

   of an intervention relative to historic controls, controls that are pulled out

   of a medical record or another kind of record, or contrasting two centers which

   may not control for every sort of bias, but controls for some.  That would be

   the second level of evidence.

        And then at the bottom level of evidence, I think there is a typo here that

   should say Class III, not another kind of Class II, but a Class III are

   uncontrolled case series or case studies or that sort of thing.

        Now, one thing to keep in mind, which I think is often forgotten in

   evidence-based methodology is that these kind of studies offer some support as

   well.  You know, basically, a case study that shows that procedures X. worked

   with a person, thus demonstrates that it worked with (inaudible).  So it is not

   a completely ridiculous thing to do, and the fact that it works with someone

   means that it may work with someone else.

        Now, of course, there is a lot of reasons why it might have worked.  It

   might be more of the procedure and less of the person delivering the procedure.

   You're left with a lot of questions.  Nonetheless, a case demonstration or level

   of controlled series of case demonstrations does provide some validity to

   procedure.
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        Now in the evidence-based methodology, those three levels of evidence are

   connected directly to the kind of recommendation that you would make for

   practice.  So if the evidence is at a level of Class I, if there is a very good

   multicenter randomized control trial that demonstrated the effectiveness of a

   procedure, then this is something that can be recommended for practice.  In

   other words, this is something you should do.  It works.

        At level 2, the recommendation is more on the level of a guideline.  So if

   you have some studies, partially controlled studies or imperfectly controlled

   studies, that's a recommendation that this is something you should consider.

   This is procedure that if your patient resembles the kind of people who

   benefited from the studies, then this is something you should pretty seriously

   consider.

        Then at level 3 -- Class III studies, basically these are procedures that

   aren't ridiculous to do.  It's not a dumb thing to do, but should probably be

   done with caution and with some careful monitoring because there is not strong

   evidence that this procedure is going to work for every patient.

        As I've been employing all along, those are the strengths and there are

   some significant risks and weaknesses with evidence-based practice.  And if I

   can get the next slide, I think perhaps foremost in the minds of many

   practitioners is that evidence-based practice may actually limit practice.

   Again, as I mentioned from the beginning, there certainly is this contention to

   providers and researchers and people, I think a minority, who feel very strongly

   that we should not be providing services that don't have a scientific basis.

        If we're honest about it, I don't know what the exact figure is, but

   something upwards of 80 percent or 90 percent of the things we do both in
                                            86

   medicine and psychology do not have a strong scientific basis.  So it's almost

   ridiculous to say we should not do those things and try to help people.

        You know, it also becomes a little silly when the effect of a procedure or

   an intervention is very obvious.  I love my friends, a name I won't mention, who

   is leaning on the side of very conservative did allow that it would be

   ridiculous to do a randomized control trial of wheelchair use.  That's pretty

   obvious.  A wheelchair helps a person who cannot walk.  So we don't need to do

   that as a randomized controlled trial.

        There was circulated on the Internet kind of this phony -- it looked very

   official.  It was very well done, but it was a phony article in a phony medical

   journal reporting a randomized control trial of parachute use and people jumping

   out of planes.  As you might suspect, the control group did not fare well.

        So there is limits to this and certainly there is much conducted -- if

   people come to us with a problem, now it's our problem, I think we are obliged

   to help them out.  Of course your first choice is if there is an evidence-based

   procedure we can use, that would be first choice, but if not, we need to do

   whatever we can to give them some help.

        So another kind of -- also part of this risk is that insurers and other

   third party payers have seized on to this to some degree and used it as a way to

   limit reimbursement.  In our cognitive rehabilitation group, for instance, I

   think we've had some success using those reviews to encourage insurance

   providers to pay for cognitive rehabilitation.  So we've had a few flip it

   around on us, this is great.  We're not going to pay for anything that doesn't

   have Class I evidence.  So that's another risk and something that we have to

   contend with.
                                            87

        You know, beyond that, there is also methodological problems with an

   evidence-based approach.  In rigorously -- in doing a rigorous controlled trial,

   a randomized controlled trial, you limit the subject population of the

   participants so dramatically that you really don't get a real world view of the

   effect of this of the intervention.  You know, you may wonder -- I certainly

   do -- about some of these drug recalls.  In this country, if anything is tested

   at a very high level of scientific rigor it's the medications we use.  So how

   come there are these medications put out to market and recalled one or two years

   later because somebody is suffering serious side effects, usually involving

   death.

        Well, the reason is that the subjects that were initially enrolled in those

   trials do not represent community dwellers.  They are people who are carefully

   selected to be pretty healthy, not to have a lot of co-morbidities and

   consequently are less likely to have side effects than people generally living

   in the community.  So it's not until you try the medication out in the community

   that you find the side effects emerging.

        In fact, I was talking with a representative from one of the major

   pharmaceutical companies the other day.  He was saying they are really leaning

   towards less controlled trials in the future.  Which I thought was kind of

   unusual because I think in rehab there has been this kind of come to Jesus with

   randomized control trial attitude, whereas the drug companies who have much

   experience with this are starting to understand the limitations of this and

   thinking more about label trials like they do in Europe in order to involve more

   people initially in the trial.

        You know, in this business of randomized control trials, they use the words
                                            88

   efficacy and effectiveness.  Efficacy meaning a trial that demonstrates the

   efficacy of the intervention, typically a medication with a carefully selected

   sample.  So, again, all things controlled, healthy people, no co-morbidities,

   right age, et cetera, et cetera, does the medication work?  Now that is a Phase

   3 trial.

        In a Phase 4 trial -- in general, the effect of the efficacy diminishes

   substantially when it is applied to a community dwelling sample.  Again, because

   we're not worrying about all these complications in the initial efficacy trial.

        To translate this into the brain injury world, for example, if you do a

   carefully controlled trial with people with traumatic brain injury, you should

   eliminate people with other co-morbidities, including who have psychiatric

   problems, have brain injury or other neurological disorders, have substance

   abuse or alcohol abuse of substantial dimension.  When you do that, as people

   who work in brain injury know, you lose about half the sample.  So what works

   for them is probably not going to work nearly as well on that group that are

   most challenging for most of us.

        In fact, if you work in brain injury, if you see somebody who doesn't have

   substance abuse or psychiatric history, you're saying Hallelujah, this is a walk

   on the beach.  It's those other ones with all those co-morbidities and

   complications that are most difficult to work with.

        So, again, an evidence-based methodology, you're really not appreciating

   the complexity of this.  Along those same lines, another limitation is this

   inattention to individual differences.  So, you know, you're looking at a

   randomized control trial.  You're looking at how the control group does on the

   average in comparison to the experimental group and looking for a difference.
                                            89

        Now, within each of those groups, there is going to be a fair amount of

   variability in the response.  You know, my old chair at Mayo was very interested

   in these individual differences.  It provides a good example of the problems

   with a randomized control trial.  But his finding is that people metabolize

   antidepressants at different rates.  That some people metabolize them very

   rapidly so you can give them a standard dose that has absolutely no effect

   because they just shoot right through their system.

        Other people metabolize them very slowly so that a standard dose is likely

   to produce a good amount of side effects because the medication builds up to

   abnormal levels in their system because of their slow metabolism rate.  So again

   imagine both of those kinds of people plus the people in the middle in a

   randomized control trial, but when you add up the response to treatment, the

   experimental group may look superior to the control group in terms of response,

   but what you're missing is the fact that some of the people in the experimental

   group have got the antidepressant and responded very poorly or they didn't

   respond at all because they were slow at metabolizing.  So translating this into

   real world practice in anything we do you find variability of response.  And a

   clinician is able to appreciate that to accommodate those individual

   differences, but the science behind it really doesn't give you much value.

        In the ideal that we talked about recently, we would have research to show

   exactly who benefits from what, by whom, when answering all those questions.

   But it's going to be many, many years in any area of practice before we have all

   those kind of answers.

        If I can have the next slide -- just as importantly as attention to

   individual differences is that in a randomized controlling trial, there is not
                                            90

   the attention to individual preferences.  What do I mean by that?  Not

   everything we offer people is acceptable to them.  Some people really don't want

   to sit and talk.  They would rather have a pill.  Somebody comes to you with

   depression.  Some of them want to talk, some of them just want a pill.  It's

   actually important to recognize those preferences and adapt our treatments

   appropriately.

        You know, in another sphere of medicine, something as basic as managing

   high blood pressure -- you know, some people don't like taking medication.  So

   while there are effective medications for managing blood pressure, some people

   just don't want it.

        Now, you know, from that rigid kind of evidence-based practice point of

   view, I guess the doctors are supposed to grab them by the shirt collar and put

   them against the wall and say take your medication!  But that's really not the

   way it works.

        You cajole, educate and encourage.  In fact, if there is a strong suspicion

   that people have a genetic loading for high blood pressure, I think a good

   doctor would want to do that, but in the final analysis, if they don't want to

   take the medication, they're not going to take the medication.  So that's not a

   great intervention.  And we do know there is other ways to manage blood

   pressure.  You can lose weight.  You can exercise, and if that's their

   preference to try to manage it with lifestyle change, a good provider needs to

   be on board to help them along that path rather than hammering away from the

   evidence-based methodology.

        My brother is an example of that.  His blood pressure was starting to creep

   up and he came in and saw his doctor.  He said I don't want medication.  I'll
                                            91

   lose weight and exercise, and the doctor's response was kind of -- oh, yeah.

   How many times have I heard that.  But in fact my brother did.  He lost a bunch

   of weight and started exercising and his blood pressure was under control and

   his doctor was quite amazed.  It probably would have been better if he would

   have been more encouraging along those lines because that was clearly his

   preference.

        Just expand on this -- I think this is an area where evidence-based

   practice really does -- just has a blind spot.  Preference doesn't only touch on

   things that are unique to the individual, but also touches upon culture.  And as

   a wealthy part of America continues to become increasingly multicultural, this

   is something else we need to be sensitive to and recognize that some of our

   interventions are simply not going to be acceptable to people either because of

   ethnic background, religious background or other cultural practices.  Again, I

   think we need to be nimble enough to adapt to that and not just get up on our

   high horse and preach the evidence-based gospel.

        When you get into behavioral practice, whether it's psychosocial

   rehabilitation or neuropsychological rehabilitation or psychotherapy or for that

   matter vocational counseling, any kind of behavioral intervention, there are

   people who would insist that we put all those practices to the test, to the

   randomized control trial litmus test.  However, I think another thing that

   viewpoint is missing is that much of what we do really is capitalizing on

   nonspecific and placebo effect.  So the very things you want to exclude in a

   traditional drug trial -- and that's reasonable.  If people respond to an

   antidepressant, you want to know they are responding to the drug, not responding

   to the fact that the doctor is nice to them.  However, when they are working
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   with a vocational counselor, the fact that the counselor is nice to them may be

   a mingled part of the intervention, a very active part of the intervention.  It

   certainly is in psychotherapy and there is a growing literature in

   neuropsychological rehabilitation and true in psychotherapy, almost any kind of

   interpersonal intervention that is a therapeutic alliance -- the relationship

   between the patient and the provider is a very important part of the effect of

   that intervention.

        So rather than trying to eliminate placebo and nonspecific effects, and

   much of what we do, we want to learn how to make the most of those.  That's

   something that gets lost in the randomized control kind of methodology.

        It's also borders and invites consideration of the differences between a

   medical model and a social model.  And this I think may be familiar turf for

   some -- for many of you, but let me briefly review it.  If I could have the next

   slide.

        So kind of back-stepping a little bit here, the evidence-based methodology

   came from medicine.  It's based on a medical model; but the essence of the

   medical model is the belief that an intervention should be directed at a problem

   that resides in an individual.  So, you know, at a very basic level a person has

   an infection in their body, we need to give them a drug or something to fix that

   infection in them.  So it's very individually oriented.  The target is within

   the individual.

        Now much of what we do in rehabilitation as well as in psychology as well

   as in behavioral science more generally, the target is broader than that.  And

   it can be described better from a social model in which intervention is as much

   directed at the social system as at the individual who is, quote, disabled.
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        So kind of like our first speaker was saying this morning, you know the

   very fact of presenting a person with disability not as a person with

   disability, but as a person with skills is an intervention and it's the kind of

   intervention that's really not directed at them.  It's not like a medical

   intervention, not a pill, not a surgery, not directed at the individual with

   disability.  They are still the same person they always were.  The intervention

   is directed at the system around them.  As she was suggesting, we're selling

   this person or presenting this person in a very different way.  And you know

   there are many people in the disability community, I would guess the most, who

   would say this is the way we should be conceiving disability.  I'm sure all of

   you are very familiar with how much the environment, both the physical and the

   social environment, interact with whatever impairment the person has to produce

   the disability.

        Many of the interventions that were evaluated in responding to TBI or

   polytrauma are of this nature and as much to do with changing our social system.

   As I think about the lectures this morning, much of the discussion is along the

   lines of we need -- meaning our society, our American culture -- needs to have a

   different view of veterans than we have had.  That is probably going to be a

   more powerful intervention if we can change our mind, change our viewpoint than

   anything specifically that we can do for a specific veteran.  At least

   (inaudible) we can do specifically.

        Kind of laying that foundation about evidence-based methodology, I would

   like to move on and review a little bit what exactly the evidence is that's

   relevant to working with individuals, veterans, warriors, returning with

   traumatic brain injury and polytrauma.
                                            94

        One thing that has come through in the literature pretty consistently, no

   matter what kind of intervention, is that the earlier it is introduced, the

   better.  And I think this is one thing our current system has struggled with.  I

   know there is attention to get the veteran back and get them engaged earlier and

   earlier.  To date, as you've heard before, we've lagged behind in that.

        I was interested to see Ms. Cohen was introducing some of the adaptive

   devices even at bedside very acutely to returning veterans.  Not that they were

   going to really be using those a great deal during that time, but just getting

   them familiar with the technology.

        In the practice at Mayo Clinic, we would do this with vocational

   intervention.  At first blush, that may seem a little crazy.  Why would you be

   talking about vocational intervention to someone who is one month post-severe

   brain injury and is just emerging from posttraumatic amnesia.  And it was just

   to get it on their radar and get it on the family's radar.  We found that just

   getting them the notion that there was some potential to return to work --

   again, I think we're very careful about how we present that, you know, but it

   might be different.  It might take some time.  Certainly will take some time,

   but the fact that most of the people, even with moderate and severe brain

   injuries that we worked with do return to work.  It gives them a good deal of

   home but allows us to make some connections.  We had a good deal of success

   getting folks hooked up with previous employers.  They were pretty good

   employees beforehand.  After an accident, if we can make a connection with their

   employer right at the time of the injury, right at the time of the accident, we

   can elicit some help from the employer to get them hooked in so that nine months

   or a year later when it was time to think about getting them back to work, at
                                            95

   least part time, we had that contact and we had that connection.  And we still

   had that goodwill.  So many reasons -- even something down the line as

   vocational intervention, get in early and maintain that momentum.

        If you look at all this from again a purest evidence-based perspective,

   believe me, these gurus in Evidence-Based Medicine are purists.  They are the

   kind of people you say what a beautiful blue sky.  It's really more azure.  Blue

   is not quite right.  I don't know what azure is.  That's good.  That's part of

   the methodology and to be picky, every I. dotted and every T. crossed.

   Nonetheless, if you talk to these purists in Evidence-Based Medicine, they would

   point out that there is absolutely not one lick of evidence investigating any

   intervention of any kind with polytrauma victims where the polytrauma is

   sustained in the theatre of war.  That has never happened before.  So there is

   no literature there.  So again if you want to take an evidence-based approach

   then just forget it.  There is no basis for it.

        Again, being much of a purist myself, I dot every I. and cross every T.  Is

   this thing on?  It's after lunch, but you all have your eyes open, so I'm

   feeling good.

        Anyhow, being a purist myself, I think we can look at some of the evidence

   in brain injury more generally, and that can be applied as best as we can in the

   treatment and care of returning veterans.

        Again, I want to emphasize if there is anything substantial, if there is

   anything solid is this principle of early intervention and that has not only to

   do with medical intervention, it has to do with early intervention for inpatient

   rehabilitation, early intervention for outpatient post-acute rehabilitation.

        Let me turn to the post-acute arena a little bit and bring up the next
                                            96

   slide.  I mentioned before there is an ongoing project to review the literature

   from an evidence-based perspective in cognitive rehabilitation.  There has been

   a couple of publications which are in your references and there will be another

   one.  This is in a year or two.  This is an ongoing process.

        Actually, from my perspective, the evidence is quite encouraging.  You

   know, we've found a good deal of indication that these procedures actually work.

   So let me give you some examples of that.  In reviewing this literature, we

   honed in on several domains -- attention, memory, language, basal abilities,

   executive functions, more multimobile and holistic programs -- and looked at the

   evidence in each of those.

        You know, this afternoon -- of course we're not going to have time to

   review that in any great detail, so I would refer you to the article.  By way of

   example, let me talk about a few of those areas that are particular to people

   with brain injury of various sorts.  The first thing is attention, the ability

   just to focus and sustain concentration on a particular task.  You know, in

   fact, there are Class I studies (inaudible) of all active units that support the

   use of attentional behavioral intervention for attention in the post-acute

   period.  By post-acute, I mean after people leave the hospital.  It kind of

   depends how long they are in coma when they leave the hospital, but in general

   we're talking about two or three months after injury.

        The kind of interventions that have been found to be most effective are

   exemplified by the work on attention process training.  I see some people

   nodding.  At least some of you are familiar with that.  These are methods in

   which a person's ability to focus and maintain attention is challenged through

   various modalities and using increasingly complex materials.  So initially they
                                            97

   may need to look for a number in an array.  That may graduate to looking for a

   number only when it follows another number.  That would be a visual kind of

   tracking test or task.  Some less language oriented or figural can be used.  The

   same kind of tests can be constructed auditorially so people have to listen for

   a particular sentence or word or piece of information in something like a radio

   broadcast and then that broadcast becomes softer or perhaps there is some

   feedback introduced or a competing conversation so that they really have to

   ignore one stimuli and focus on another.  Those are the kind of tasks -- again,

   delivered in a graduated fashion -- so that initially they can have some success

   in looking at a relatively -- or paying attention to a relatively simple array,

   but then are challenged to manage and focus their attention on increasingly

   complex information.  So it's that kind of an intervention that most of these

   studies -- or Class I studies have investigated and it in fact found benefit for

   people with brain injuries for these kind of interventions.

        Another component to those post-acute interviews is that people are taught

   strategies along with simply being challenged.  What can I do to keep my

   attention on this conversation when people over here are talking about something

   else.  What can I say to myself?  What can I do physically in terms of turning

   away and looking at the person I'm talking to.  Learning a strategic approach to

   regulating attention seems to be of benefit in enhancing attention during the

   post-acute period.

        So pretty good evidence -- I mean the best Class I evidence that attention

   interventions are effective in the post-acute period.  Now, we also found that

   these very same interventions were really not effective compared to trials

   during the very acute period.  So the first months or two or three after injury
                                            98

   when these interventions were introduced in an inpatient rehabilitation setting

   in general there was no difference between the control group and the treatment

   group.  Now, why is that?  Well, they are confused and also they are recovering

   very quickly.  So in that acute period, it's really hard to stay ahead of

   spontaneous recovery.  Either people are too confused to do the test or once

   they take off, they take off so quickly they are really not going to help them

   much by introducing this intervention.

        That is good to know because that kind of tells you where to put your

   resources.  Don't waste your time while they are in the hospital.  Wait a few

   months and then this will be a great help to them.

        Another area that has been investigated relatively well is the area of

   memory.  It's interesting when you -- I know Dr. Nemeth is well aware of this --

   that when people come to you and say they have memory problems, that could be

   anything.  It could be memory meaning that they have difficulty in coding and

   retrieving information or it could be attention, you know, that they just don't

   focus or it could be some higher level problem where they are not able to put

   things together in order to get them into memory.  So evaluating that through a

   neuropsychological evaluation is often important, although we have no evidence

   for that.  No one has ever tested that out, however, it just makes sense I think

   that you would want to know what problem you're addressing before you jump in

   there and address it.  So if somebody comes to you and says they have memory

   problems, you have to figure out exactly what that means.

        If you've convinced yourself that in fact their problem is getting things

   into memory and/or getting it back out, there are behavioral interventions that

   work.  And there are several different approaches to developing memory skills.
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   You know, one is to teach people various strategies for remembering.  And again,

   some of you may be familiar with some of these kind of mnemonic strategies and

   skills.  This is the kind of things that these (inaudible) are just marvelous

   at.  They have all these little tricks for coding things in memory so they can

   remember 85 people who were just introduced to them.

        The skills themselves are difficult to execute.  For those of you who

   aren't familiar, what this would be, for instance, is -- I'll use Dr. Nemeth as

   an example.  She has that name that's easy to remember.  So now whenever I see

   her, I'll think of Broadway Joe and I'll never forget Dr. Nemeth, but

   unfortunately my friend Stan (Polish name) does not have such a name.  So that

   one is a real challenge you know to develop an association.  When people teach

   these kind of memory tricks, they usually use -- oh, let's see, let's try to

   remember Sheryl Crow's name.  How would you remember her name?  Well, I guess

   I'll picture a crow.  That's easy, but when you get down to real life cases,

   it's very difficult.

        Actually I'll give you a trick for remembering my name, Malec.  It's an

   anagram for camel.  So if you rearrange the letters, you'll come up with Malec.

   I hope you're getting the idea.  These are a lot of work.  These techniques are

   a lot of work.

        So it's only -- although they are effective and have been shown to be

   effective in randomized control trials, both with normal people and people with

   mild memory problems.  However, with people with more severe memory problems,

   they are generally not effective or with lazy people like myself because the

   reason they're not effective with people with more severe memory problems is

   that first off they are not organized enough to use them.  I mean these are high
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   level, complicated strategies.  So you have to think to use them.  You have to

   remember how to use them.  So if you have very serious memory problems,

   cognitive problems, you're not going to be able to do that.  Plus there is the

   laziness factor.  I'm one of those.  I can say Hi, I'm Jim.  I'm lazy.  This is

   just too much work.

        So if I -- you know, if I want to remember Dr. Nemeth's name, I'm going to

   have it in my palm pilot someplace.  I'm going to have it associated with

   Southern Louisiana so when I see her five years from now at a meeting, I can go,

   oh, yeah, okay.  Nice to see you, Dr. Nemeth.  That is the other approach to

   memory rehabilitation.  Helping people learn compensation, the second approach.

   There is a third.

        The second approach to memory rehabilitation is to teach people external

   strategies and teach them to use externally to help them manage their memory

   problems.  So the idea of, again, advanced by (inaudible) years and years ago

   that you are using a memory notebook and organize that memory notebook in such a

   way that you can actually find the information you put in there.

        You know, in our practice -- and again, Dr. Nemeth is going to be nodding

   with me on this one -- because in our practice it's quite common for us to be

   talking to someone who comes in after brain injury with memory problems and we

   ask them, do you write things down?  Oh, yeah.  I write everything down.  Then

   they usually reach in their pocket and pull out a wad of sticky notes and say

   it's all in here.  But they have no idea where it is in there, and then they

   have similar wads at home.  So what we do is pull apart their sticky notes and

   start to put them in a book that's organized so they have a section for their

   children, a section for health care, a section for school or work, and you know
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   the books are designed to suit their needs.

        This gets back to the idea of personal preferences.  I remember there was

   one guy we had in our brain injury program a few years ago who was actually a

   construction worker but at a fairly high level.  He did heating and cooling, and

   it was fairly sophisticated kind of construction.  He wasn't on the nails into

   wood.  He had to design systems, and so he also had to remember a fair number of

   things about room dimensions and the relationship to the rest of the building so

   he got enough area -- a big enough pipe going down where he needed to.  And of

   course after his brain injury this is much harder for him.  We thought he was --

   are we getting to the end here?  So we thought having a memory notebook would be

   fine.  So the O. T. brought him -- I'm looking for somebody who has one of these

   elegant booklets about this size, leather bound.  There we go.  These are

   wonderful.  Ladies like these.  This is highly preferable, that kind of a

   notebook seems to be highly preferred by women.  And this guy -- again this guy

   was a man's man.  What?  No, I can't carry this, among other things, the boys

   would have laughed him out of the workshop.  So this wasn't going to cut it.  So

   we eventually ended up with a tiny little three by five notebook that he could

   stick in his pocket.  Not ideal in terms of keeping track of things.  It's

   harder to organize this, but for this guy, it was the best, and a man of few

   words.  He didn't have a lot to write down, but everything important went in

   that little notebook and he knew where it was.  Paying attention to his

   preferences I think made a big difference.  In effect, it was a very effective

   intervention for him.

        Now the third kind of intervention that is probably most applicable to

   people with very severe memory problems, his system in which they don't have to
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   remember anything, somebody tells them when something important is happening.

   With modern technology, this is really beyond me, you know much of it was tested

   using pager systems.  Barbara Wilson and her group in England using pager

   systems that were designed especially for this, but as I understand it, you can

   actually program your home computer to give you a call and tell you what to do

   next.  So -- and I don't have this knowledge, but if you could hook up with

   somebody who has the knowledge of how to do that sort of thing, all of us that

   have problems -- especially if you have a patient who has very severe memory

   impairment, you can design a system so every hour somebody calls them up and

   says five minutes before the hour.  You have a meeting or this is your duty or

   it's time to go to the store.  Or today is Wednesday, you have to take out the

   trash and reminds them to do what they need to do.  So really these three levels

   of intervention -- the first being the mnemonic strategies.  They do work for

   some people.  They just really want to keep it all in their head and again I

   usually try to convince them that that's a bad idea.  That all of us have too

   much to keep in our heads, but some people just really want to do it that way.

   Again, there is good evidence that that works.  That may be the preferred

   intervention for those sorts of people.

        At another level, using a memory notebook or a palm pilot -- I was

   interested in the comments about the use of adaptive devices for memory.  If

   people are familiar with those devices before their injury, they are able to

   transition back to them pretty well.  If they are not, it may just be too much

   for them.  Again, paying attention to individual preferences there is also

   research to support that sort of intervention.

        Finally, with a person with very severe memory impairment who simply may
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   not be able to remember hardly anything.  The idea of a pager system or a

   prompting system for which they really have no responsibility but are just

   reminded of the things they have to do has been tested Class I evidence works

   very well.  So it's more a matter of paying attention to individual differences

   and selecting the best procedure for this person.

        So good news in those areas.  But in the area of executive function, and by

   this I mean -- to some sense executive function is kind of a catch all garbage

   can kind of category of all the higher level things we do every day.  And

   actually along those same lines the most important things we do, the really

   critical things.  You know, we we're not called upon to make important decisions

   every moment of the day, but when we are, those are a critical juncture.  And

   especially after traumatic brain injury, people are usually not able to do that

   as well or maybe not at all.  So they tend to either not be able to make a

   decision or they are impulsive and make the wrong decision.

        There are some preliminary studies to suggest that people can learn to do

   this better, that people can learn problem solving strategies even after mild to

   moderate severe brain injury that assists them in compensating for these kind of

   deficits.

        There is also some preliminary evidence -- and some of these are Class I

   studies, although not terribly strong Class I studies -- I mean randomized

   control studies where people can learn higher level communication skills.  You

   want to think of that as an executive function being able to monitor your

   conversation, monitor your dialogue with somebody and respond appropriately,

   kind of know when to shut up and listen and when to say something and how to

   construct what you're going to say to people so it has a beginning, a middle and
                                           104

   an end.  All of those could qualify as kind of higher level language activities.

        There is preliminary evidence to suggest that interventions in those areas

   are effective because it strengthens the evidence.  It's not nearly as good as

   in these other areas, so this is one of those areas where you know more research

   is needed.

        Getting back to the principles, does that mean we shouldn't do anything

   then?  Of course not.  There is some evidence -- it's not as strong -- but there

   is some guidance about what to do.  Mostly continue to try to figure out what

   works best for different people.  We really don't have the clinical basis to

   design the research that we need to really hone in on the effective components.

        Let me move on to other types of interventions so another area that's

   frequently disturbed after brain injury, that includes polytrauma, is the

   emotional and behavioral abilities and components of a person.  We know that

   depression is prevalent among most all disabled populations and people with

   brain disorders and stroke, the statistics are a little variable, but it's

   reasonable to know that the majority of people who experience a significant

   depression at someplace in the first two years after a brain injury.

        So we know that this is a prevalent disorder.  We also know that there is a

   group of patients that have not become depressed, at least not for awhile

   because they have another kind of problem, which is that they are so cognitively

   impaired and have this kind of high level impairment that makes it impossible

   for them to conceptualize what's happened to them.  So these are -- like

   Dr. Cohen was describing someone who was just bound and determined to go back to

   Iraq and had no idea really what the impediments were.  I'm guessing that many

   of you have worked with people with brain injuries like this who are bound and
                                           105

   determined to go back to be superintendent of schools or whatever and really

   have no idea that memory and other cognitive problems completely preclude that.

        So we kind of have two different syndromes that emerge after significant

   brain injury.  And the two can occur simultaneously and certainly as people get

   involved in rehabilitation there may be a dawning awareness and then you kind of

   see this seesaw between getting depressed and kind of retreating into maybe what

   now is as much denial as lack of awareness, and so a very complicated kind of

   syndrome.

        You know, depression and diagnosing depression after brain injury is

   challenging at times because people can also have many symptoms of depression

   but in fact aren't depressed.  I don't know if this is a common term, but one

   that we use is abulic.  So anyhow, abulia means they lack initiation.  They lack

   the ability to smart behavior and also their facial expression is usually not

   animated.  So when you look at them, they look depressed.  They don't do

   anything and they act depressed; but if you can get them to talk, they are

   really not depressed -- at least not always.  So that's a different thing than

   depression.  It might be better treated with a psychostimulant or something

   other than a traditional antidepressant.

        And then on the other side of that, if the person is not abulic, they may

   be disinhibited.  Those of you who have worked with people who have lost the

   ability to inhibit their behavior after brain injury, that's a real roller

   coaster ride.  They react impulsively.  They do all kind of crazy things, and if

   they were wild and crazy people before the injury, things are now ten times

   worse.  And unfortunately that syndrome often goes with that whole lack of

   self-awareness and then you've really got a tiger by the tail in working with
                                           106

   this kind of person.  So it's our job with those people to make them

   depressed -- I'm being a little facetious.  (Laughter).

        But in fact that is unfortunately part of it is to try to build enough

   awareness that they can begin to engage in rehabilitation.  Unfortunately, as

   that awareness builds, they often become depressed and that requires

   intervention.

        Now, we do know, and there is good evidence, that all of those things

   negatively impact on outcome and they interfere with rehabilitation.  When a

   person is depressed or disinhibited or lacks self awareness, that's going to

   make rehabilitation more difficult.  It's probably going to require longer and

   more intensive rehabilitation.  Certainly those particular problems are going to

   require specific intervention.  So all of those things are a negative effect on

   outcome.

        What do we know about treatment efficacy?  From a scientific point of view,

   very little.  There really has not been -- this may surprise you -- there has

   not been at least to my knowledge any randomized trial of people with depression

   with brain injury.  The same for all those other kinds of interventions.

        So if you are adopting a strict evidence-based methodology, you'll say we

   have nothing to offer.  And as Dr. Nemeth will support me, we have much to

   offer.  We have many reports over the last 30 years of success with this very

   challenging kind of patient.  So there is something we have to offer.  Maybe the

   next challenge is to find ways to evaluate that so we can do it better and more

   consistently.

        If I can have the next slide, another important area for examination and

   intervention after brain injury is the family context.  You heard a little bit
                                           107

   about that already.  Family support has a good deal to do with outcome, again,

   after any disability, but particularly after brain injury and polytrauma and

   when people are cognitively impaired, the support they get from their family --

   and when I say family, I'm using that fairly generically.  I read someplace that

   some surprisingly large proportion of families were nontraditional.  Meaning

   that people who call their families were sometimes blood relatives or sometimes

   not.  People they lived with.  It's basically what they call in Australia close

   others.  I kind of like that word, they are close others.  So we'll just call

   them family for today.

        Their family is very important because there are periods where this person

   really may not be able to get a handle on what's wrong with them and they really

   need those people around them to keep them on the right track.  In fact, in our

   brain injury program at Mayo, we regularly got people into the program who are

   only there because their family brought them there every morning and shoved them

   in the door.  Left to their own devices, we would never see them again.  And

   many of them benefited.  The family support is very important.

        We are involved in some research recently with the people at TIRR and

   Baylor at Houston and with people in Mississippi Methodist in looking at family

   dysfunction when people first showed up on an inpatient rehabilitation unit.

   And we were surprised to find that 25 to 30 percent of families were already in

   some distress before the injury.  I guess for most of my crew, I just assumed

   when families were distressed after injury was because of the injury.  In fact,

   it's one of those -- duh, why didn't I think of this before -- you know,

   families do go through periods where they have some distress or dysfunction and

   in fact when you look at a consecutive series of people coming out of the brain
                                           108

   injury and rehabilitation unit, about a third had some dysfunction before they

   even hit the unit.  I think the red light for me is that's important to

   identify.  That's important to intervene.  Now you're not only dealing with

   trying to enhance family functioning, but you're trying to address a preexisting

   problem that is really just going to snow ball if it's not addressed.

        And in fact in retrospect, as I thought about all this in terms of my

   clinical experience, I think it's true that families that are functioning pretty

   well get closer when a serious event like a brain injury occurs.  So you really

   see families pull together, whereas families that are not functioning well, it

   just makes everything worse.  It's a stress they really can't tolerate.  So

   that's the group you really need to intervene with.

        Of course there is good evidence that it has a negative effect on outcome.

   Plus the evidence that anything we do makes a difference -- very little.  Really

   no good studies -- at least not with adults -- to show that family intervention

   makes a difference.  In fact, it's been surprising to me that the few studies

   that have looked at this have generally shown that these families are

   functioning pretty well.  And it makes me think again that the families that

   we're recruiting for these studies to enhance family functioning are the

   families that are already functioning pretty well.  They are the kind of people

   that, oh, yeah, I want to do better.  I love my kids.  I'm going to get in

   there -- it's not the families that (inaudible).  Those aren't the people that

   show up to the session.  So, there again, lies the challenge for an

   evidence-based approach.

        I think another question or another dimension on family intervention is

   what is the efficacy of support of intervention?  It's our belief -- I believe
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   it -- that providing families with ongoing support almost indefinitely is a good

   thing.  Some of that support may come from professionals, some from peers and

   brain injury associations and other families.  Again, do we have any evidence of

   that?  Sorry, no.  Does it mean we shouldn't do it?  Of course not.

        Let's go on to the next slide.  We're going to about 10 till; is that

   correct?  I just want to make sure I have the time right.  These are the sorts

   of things you could talk about for a long time.  I think each of these slides

   could be a half a day workshop.  I'll try to reel it in here.

        You know another concern that's important to evaluate in brain injury and

   polytrauma -- actually in any kind of disability, but we're focusing on those

   today -- is substance abuse.  It is probably a little more common among brain

   injury survivors than some other disability groups simply because alcohol is

   often -- well, motor vehicle accidents are the second most.  I think falls have

   surpassed them.  They are occurring to people above the age of 65.  If you look

   at your young adults, I think motor vehicles are still the primary cause of

   brain injury and in many cases alcohol is involved in those motor vehicle

   accidents.  It doesn't mean that everybody is an alcoholic.  In too many

   unfortunate cases where a 17-year-old had his first experience with beer and

   ended up wrapping his car around a tree.  But nonetheless, there is some reason

   to think that a brain injury population may have a higher representation of

   people who have trouble with alcohol than other disability groups.

        And it is another condition that we have clear evidence that impacts

   outcome.  We have good evidence coming from Ohio State that people who drank

   significantly before their injury are very likely to return to alcohol use after

   their injury, and that when they do, that has a dramatically negative effect on
                                           110

   outcome.  So we know it's a problem.  We know we need to address it.  It's a

   difficult problem to address.  I think screening -- I'm sure many of you know

   figuring it out if a person says they are not drinking because they are not

   drinking or whether they are saying they are not drinking because they are

   alcoholic and don't want you to know they are drinking is a real challenge.  But

   the degree that we can pay attention to that and look for telltale signs and

   hone in on that is important to do so.

        What evidence do we have that those kind of interventions are effective?

   Again, very little.  I think John Corrugan and the group at Ohio State has done

   a wonderful job for laying the foundation for the problem, the dimension of the

   problem and done a good deal to identify ways to screen for alcoholism and other

   substance abuse throughout the rehabilitation process so that we're identifying

   people for whom we need to attend to those kind of problems.  Any well done

   Class I trial of any intervention, we just don't have it.  There is not real

   good evidence for any kind of intervention with alcoholism.  It's a problem.

   It's a hard one to address successfully.  Again, does that mean we shouldn't do

   it?  Well, of course not.

        Let's look at the next slide at one of my favorite areas, vocational

   intervention -- maybe one of your favorite areas, too.  I think this is the one

   for this audience.  Don't forget if I get up on my soap box about vocational

   intervention because I think particularly as we get into this area, we get into

   an area where you really have to ask yourself, do we really need to test this

   with a randomized control trial?  And does this even make any sense?  You know,

   when you think about what you all do or what you all will do, it's really

   complicated.  You know, I mean you're working with individuals.  You're working
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   with families if you can.  You're working with social systems.  You're making

   connections.  I've been kind of an observer of this for 30 years.  So forgive me

   if I don't have the intimate knowledge that you do.  It looks like rehab people,

   the best ones, are networkers par excellence.  They have all the connections.

   Here we know that transportation, for instance, is the biggest obstacle to the

   return to work.  So if you want to be a good vocational counselor, you'll just

   have to go about getting this person a job but how to get them there and who is

   going to do that and who can you hook up with or who can they hook up to to make

   that happen.  Is that a church group or a friend or a bus line, how does all

   that happen?  So you've got a very complicated intervention that is also I think

   generally unique to the individual.  It's hard to think of two episodes that are

   the same.  And then you've got a situation where neither party can really be

   blinded to the intervention.  What are you supposed to do?  Talk through a

   screen or something?  You know what you're doing for the person.  The person

   knows what you're doing for them, and certainly if they were in the control

   group they'd figure that out.  Probably write a letter of complaint to the

   administrator, so how do you jam all that into a randomized control trial?

   Well, you could.  You can do one person gets the intervention, one person gets

   standard of care which means nothing.  But I have to ask myself and I'll ask

   you, what sense does that make?  Thank you.  Give it an amen.  And again, this

   kind of intervention to me sits much better with a social model of disability.

   Because again that's forward intervening.

        I'll tell you an embarrassing story by one of the patients we worked with

   years ago.  This was one of these -- just to make the point about intervening in

   the social system and getting the context correct.  This was one of I would say
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   the most disinhibited, unaware character we ever worked with.  And he was just

   unpleasant, you know.  And he was a complete (inaudible).  He was one of these

   guys, a woman walked by, he had to comment.  And so as you might imagine, it was

   very hard to place him.

        He was disinhibited, so he didn't want -- we thought about trying to find

   some place to keep him in a basement some place where he could do something.  He

   wanted to be out there and he wanted to be social, so that wasn't going to work.

        So he failed several placements with a great deal of coaching.  He would

   last two days because he'd make some inappropriate remark and out he would go.

   They were just intolerable.  I don't mean to make this sound funny.  He was a

   nasty character.

        And then so we tried -- the vocational counselor finally hooked him up in

   doing some cooking in a fast-food restaurant.  He had some experience with this,

   and he and the other chef were back there.  He could be social and few people to

   interact with, so there wasn't a lot of interaction.  He didn't have to interact

   with customers, so this was kind of the last try.  A day went by, two days went

   by, a week went by and no phone call.  We are figuring he must have killed

   himself or something.  By now he should have got bounced out of there.

        The vocational counselor calls up and gets the other chef.  Great.  I love

   him.  And our vocational counselor at that time was a woman and so she said I'm

   going to come by and see.  She goes by to see.  The other chef is like, well,

   honey, aren't you quite a nice looking person.  He was just as bad.  So you have

   one off par, gender equality and one for a successful placement.  We found the

   right place for this guy with another male chauvinist pig.  We got him a job.

        And you know part of that story is finding the right context is so
                                           113

   important to the success of this and looking at things from a social model.  We

   didn't do a thing for this guy in terms of making him a better person, but we

   did find a place in this world where maybe he can survive and not get himself in

   jail and not to make the world terribly unpleasant for everybody else.

        And this is also an area -- again, I think I don't have to tell you all --

   where nonspecific effects are important.  Putting a lot of English on the ball

   and getting that relationship going so that we can keep people encouraged and

   headed in the right direction.

        If I can have the next slide, I just want to review the evidence in this

   area a little more in depth and try to illustrate why this is -- vocational

   rehabilitation is probably not appropriately evaluated from an evidence-based

   perspective.  So just to give you a brief view of employment after traumatic

   brain injury, just moderate TBI, we see those cases of mild TBI where there are

   problems, but most people who have a single concussion, a single mild TBI

   recover completely after a number of weeks.  So we won't think about them.

   We'll deal with folks with more severe brain injuries.

        If I could have the next slide.  If you look at the historical literature,

   when people -- before people got interventions with any consistency -- in fact,

   there is parts of the United States where they don't, but when people looked at

   the natural history of brain injury, there have been a number of studies I have

   listed there to see how many people returned to work or got to work.  The

   results are pretty consistent.  40 percent is kind of the high point although

   most studies did not find that.  It was more 30 percent and less.

        Now, if you look at historical literature and if you give me the next

   slide, you see a much different story in which there was some intervention,
                                           114

   specific intervention after brain injury.  And in these cases, the percent of

   return to work is upwards of 50 percent and usually is really hovering around 70

   or 80 percent.  Kind of dramatic difference.

        Now, none of these studies that I've listed were truly randomized

   controlled trials.  A few have historic controls.  For the most part, these are

   cohort studies where people intervened and reported outcome.

        If you give me the next slide, I'm trying to drive the point home.  If you

   look at the natural history of traumatic brain injury, what you find is that

   without specific intervention, only 30 to 40 percent are employed.  With a

   specific intervention, those statistics are turned on their head so only 30 or

   40 percent are unemployed.

        At this point I have to just stop and think why do you need to do a

   randomized control trial?  What's the goal here?  Isn't it to get people back to

   work?  You know, I don't care if you do a magic trick and you're getting

   70 percent of the moderate to severe brain injury population back to work.  That

   would be great.  We could read Reader's Digest together and (inaudible).  No

   matter what you do, if you can get 70 percent of people with moderate to severe

   brain injury back to work, just keep doing it.  We don't really have to stop and

   check why that works.  So I think this is an area where evidence-based

   methodology leaves a lot to be desired.  We really should look at it from a

   social model perspective.

        You know I'm going to belabor this point a little more because I feel so

   strongly about it and show you the results that we've been reporting at Mayo for

   several years.  If I could have the next slide.  Would you just click through

   that.  I think there is some animation there.  It's not ideal because they are
                                           115

   fading out.  Go back to the other one for just a minute.

        It's on your handout.  We looked at (inaudible), a relatively simple scale.

   That ranged from people who are working in the community at least 15 hours a

   week without any support.  So independent, competitive employment, in fact, most

   of these people were working more around 30 hours, 30 to 40 hours a week.  So it

   really was a good placement, we just didn't know where to draw the line and drew

   it at 15 hours.

        One down from that, the level was called transitional.  These are people

   who are working in the community with some support, but support we expected to

   fade over the next year.  One down from that was supported employment.  You have

   people working in the community with some support that we expected to be needed

   indefinitely.  One down from that was sheltered.  You all know what that is.  We

   do not consider sheltered employment a good outcome.  And then bottom rung was

   unemployed.

        I'd like to have the next study.  We looked at a couple of cohorts of

   individuals who had a variety of interventions including specific vocational

   interventions.  And again these are pretty severely disabled individuals.  These

   are people with moderate or severe brain injury who typically lack

   self-awareness, have pervasive neurocognitive disorders -- a challenging group

   to work with.  Nonetheless, as you can see from the slide, after these

   interventions, we were able to place about 50 percent without support in the

   community.  And another 25 percent with transitional supports and about another

   10 percent with indefinite support.  We followed up with them after a year and I

   think the most important thing to recognize is those numbers didn't change that

   much.  We did see that we had a few more people working without support.  Now,
                                           116

   the ones who are still in the transitional area are usually people who were

   still in some kind of training program at one year.  That's why they ended up in

   that category.  If you do the math, what you find is about 70 or 80 percent of

   people with these very significant brain injuries were able to return to work in

   the community with and without support and more importantly maintain that

   employment for at least one year.

        If you go to the next slide, we replicated that study subsequently with

   another contention and found much the same results.  The one difference you'll

   notice is that we placed fewer people right after the program into unsupported

   employment.  I think the reason for that is as time went on, we were able to

   identify more support and that's really our preference to transition people with

   support if we could, but at the end of the year, you find much about the same

   thing.  We have about 80 percent working in the community with or without

   support and a surprising number working really with very limited support through

   this kind of intervention.

        Many of these people -- actually I'm sorry I didn't bring the slides with

   me.  At least the cohort of these people were seen years after injury.  We

   showed similar rates of success even for those folks although typically the more

   chronic patients needed support than did not.  Kind of an argument for early

   intervention, but also an argument that this intervention made a difference

   because these were people who had been struggling for years and years to return

   to work and now we introduced the intervention and they went back to work and

   sustained it for a year.  Why do you need to do a randomized control trial?  It

   makes sense to me.

        One more area before I start to tie it up is -- I think this is something
                                           117

   that we do too often, but it's the need for follow up just for maintaining

   contact with people after brain injury.  Especially brain injury complicated by

   polytrauma.  In fact, there has been a randomized control trial done at the

   University of Washington, a multicenter trial, showing that telephone follow up

   does improve outcome after brain injury.  So we have the scientific evidence.

   We don't have a lot of detail about how much and how long and with whom and

   about the value of establishing a supportive network.  So there are a number of

   questions left unanswered, but still at least preliminary studies suggesting

   that this is something we should do and certainly, you know, on a clinical level

   we've been very impressed over the years that having -- or helping patients to

   establish a support network and giving them points of contact we feel like is

   critical to sustaining the success of any intervention.

        Getting back to the vocation area, I haven't had a chance to talk about

   this in great detail, but one strategy that we've used that is quite important

   is to educate employers when a person with brain injury is returning or signing

   on with an employer.  About answering their questions, addressing any of their

   fears.  Sometimes they have some fears that don't make a lot of sense, but they

   just don't know.  So we help them understand, and we thought that was important.

        A component of that is also telling them -- the vocational counselor

   telling them if you have any problems, call me.  Usually they don't, but it

   makes them feel so much better to have a card in case something goes wrong and

   also -- and also we've saved a fair number of placements because they have

   called us.  You know, typically the scenario is, I don't know what's going on.

   He was doing so well.  This is six months after placement.  He was doing so well

   and now he's just crazy.  I'm going to have to fire him.  The vocational
                                           118

   counselor is pretty experienced.  Uh-huh, uh-huh, why don't I come down and see

   what's happening.  And of course what's happening is something has changed in

   the work routine.  And so our vocational counselor waltz' in and figures out

   what has changed, and if the patient and employer are okay with that, things are

   back on track, tomorrow is a new day.  Everything is fine.  We're good until the

   next change.  So that is quite a contact is both a reassurance to the employer

   as well as sometimes a safety net that we need when things are starting to go

   wrong.  And I'm talking about employers, families, spouses, et cetera, just to

   have a call back number where somebody will be on the end of the phone and can

   respond.

        If I could have the next slide, I'll try to bring this back a little bit to

   the ethical perspective.  I was not familiar with the distinction between

   morality and ethics, but it's a good one, and I think some of what you'll hear

   from me during these last few minutes is along the same lines.  Because I think

   it's a question, what is ethics exactly?  Is it a set of rules or is it more a

   level of awareness and appreciation?  I'd argue with Dr. Nemeth that it's really

   that awareness and that sensitivity that allows us to put our ethical principles

   into action.  I hope you'll appreciate from this review of the evidence we have

   some clues -- we have some basis for some of what we do, but there is certainly

   not a road map here.  There is not a loose leaf binder with here is how you

   treat traumatic brain injury, and certainly not one with how you treat traumatic

   brain injury with polytrauma sustained in the theatre of war.  It would be

   empty.  So to large degree, we're kind of doing the best we can, like McGuyver.

   We're doing the best we can with the material.  And I suggest, as Dr. Nemeth did

   also, that that is the ethical way to practice.  So if you give me the next
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   slide, I'll lay down a little more specifically.

        So what would ethical practice be?  In my opinion, it would be aware of

   current scientific knowledge and also best practices.  There are some things

   that have scientific validation, and we talked about some of those and there are

   others that are best practices meaning that the people that are respected in the

   field suggest that this is the way to do it.  They've been able to have some

   success in the terms of the cases they've worked with.  So knowing both those

   things is incumbent on practitioners in order to practice ethically.

        Also it's the awareness of the current situation.  There is limitations on

   what you can do depending on -- in the United States depending on the funding

   that the person has, where they live, where they have been, who their family is,

   so you may adjust -- again, I think I offered a few examples of that.  Where we

   adjusted our practices to accommodate the individual differences and preferences

   and contexts that the person was living in.  And to give you a concrete example,

   I actually heard of stories -- you know, when the brain is injured severely, it

   often swells and if there is bleeding, you know, that can increase the pressure

   and if that process is allowed to continue to occur, the person will be dead

   within minutes.  When neurosurgeons see that happening in the hospital, they

   will typically get some sophisticated equipment and drill a hole to relieve some

   of the pressure.  Sometimes open up the entire skull, but oftentimes the hole

   will be enough to relieve that pressure.

        You know, I've heard of surgeons in the field -- or actually I heard of a

   story of a surgeon on an airplane where they saw this happening, pull out a ball

   point pen and make the hole.  Now, again, just to emphasize the context, using a

   ball point pen in a hospital setting would be grossly unethical.  To use it in
                                           120

   an airplane 50,000 feet off the ground with a landing strip 300 miles away was

   absolutely ethical.  There was no other choice.  Context is important in making

   these kind of decisions.

        So we've talked quite a bit about the awareness of individual needs and

   preferences.  The over arching principle is to optimize the person's life, and

   fitting our interventions to their needs and preferences is critical to have a

   good outcome.

        And then being able and being equipped to monitor all that on an ongoing

   basis because people change, situations change, contexts change, preferences

   change.  So you have to be nimble enough to adjust your practices and keep them

   on track with that individual as things progress.

        And you know above all, I think it's another one of those over arching

   principles is above all doing no harm.  Just a watch word in medicine, and I

   think one for us all to appreciate, kind of a balance against really wanting to

   try to help is also being a little cautious.  Sometimes things we do to really

   try to help actually make things worse.  So again that's part of the monitoring

   process.

        So with that, why don't we move on to the next slide and I think you have a

   list of references in your handout that talk about -- they will tune you in to

   some of the guidelines that are available for practice in TBI and polytrauma

   generally.

        And the last slide is the rehabilitation hospital in Indiana.  I retired

   from the Mayo Clinic recently and moved on as research director at this new

   facility.  A wonderful facility in Indianapolis, and I'm really enjoying the

   change.  When I left Mayo -- I didn't have to retire, but I was able to after 23
                                           121

   years, but some of my colleagues accused me of a mid life crisis.  It's way too

   late for that.  I don't know what this is.  This is a late life crisis.  Anyhow,

   it's a great group of people to work with, and I'm really enjoying it and the

   focus is on research.

        So with that, I thank you very much for your attention after that wonderful

   big lunch and do we have time for a few questions?

        You know, we are doing a number of things, and I hope to do more.  That's

   one reason why I signed on there.  The major patient populations that we serve

   on brain injuries, people with brain injuries, stroke and spinal cord injuries.

   Much of the research being done now is with brain injury.  There is one study

   going on with a family intervention.  There is another study going on with

   behavioral effects -- a little more medical, but the behavioral effects of

   certain types of medications.  There is also some interesting studies of spinal

   cord injury and actually trying to encourage the regeneration of the neurons,

   and it's really quite mind-boggling trying to encourage the nerves actually to

   regrow in a functional way.

        >> AUDIENCE MEMBER: (inaudible).

        >> DR. MALEC:  Yes.  Before I left Mayo I was director of their TBI

   assistance for nine years and helped them get refunded before I left, and I

   continue to be connected with that group and hope to continue with some of our

   research which is focused more on vocational stuff and surprising for us as one

   of the premier medical centers in the United States, the folks (inaudible) is

   really very psychosocial and one of our major studies is an advocacy program

   that we hope to demonstrate will be effective and something that we can share

   with other people.  Thanks for asking that.  Other questions or comments?  Thank
                                           122

   you.

        [APPLAUSE]

        >> DR. KUNDU:  We have some questions from the computer?  I'm going to read

   a couple of them.  Dr. Nemeth will answer one of them.

        This is from Thomas Langham from Wisconsin.  You mentioned the captioning

   for the hearing impaired but didn't mention the audio description training

   (inaudible) for all material just as you do for captioning.

        I talked to Dr. (inaudible) from the National Clearinghouse and she will

   have all of this on a website and it will be described.  We'll respond to you by

   E-mail.

        Another question from Savannah, Georgia.  Can you speak to the problem the

   fact that the most common disability of this war is TBI presents to counselors

   and employers?

        And another one from (inaudible).  My name is Lynn in Tennessee.  Can you

   give the complete name of the DVD from Walter Reed and a contact phone number

   and how to order it?  Yes, we will get it from Ms. Cohen and she will give you

   information.

        Another one from Tampa Bay, I broke my neck in 1956 while serving in the

   Navy.   (Inaudible) business administration in 1968.  I had to rely on my wife

   driving me.  At that point in time, the assistive technology -- Internet was not

   available.  (inaudible).  I was offered an opportunity to become an entrepreneur

   by organizing a mutual fund and a securities dealer and investment adviser all

   of which I have to do with a manual calculator and self-study (inaudible)

   incorporating requirements and licensing requirements.  The point of this is

   that persons with disabilities need to look at what they can do, not what others
                                           123

   can do for them and become their own advocate.

        Okay, now the question for the -- you can read it, and if you like you can

   take a break and have some drinks.

        >> DR. NEMETH: This question is -- I am particularly interested in the

   impact on the families.  What specific challenges do the families of veterans

   with disabilities face?  What can family therapists do to help these returning

   veterans with a smooth transition?  What help or support is available for

   spouses, parents, children and family members?  And this is from Cynthia Hendley

   from Maryville.

        In terms of this very useful question, you just heard Dr. Malec state that

   keeping in touch with the injured person and their families is crucial not just

   two weeks after the program ends or two months after or two years after, but

   really for a lifetime.  Somebody needs to be monitoring that.

        In terms of families, I'm going to ask all of you to read the wonderful

   article by Dr. Lezak.  Dr. Lezak is a very, very close friend of mine and any

   neuropsychologist will know her name.  I mean, she is the premier

   neuropsychologist.  She's written all the books that we consider Bibles.

        Well, her main article is brain damage is a family affair, and that was

   written in 1988.  So first and foremost, everybody who is dealing with families

   of brain injured persons needs to read Muriel's article.

        In my handout, I have summarized a few of the points.  One is that the

   problem -- we have sound problems here.

        (No audio).

        >> DR. KUNDU:  Laurel.

        >> LAUREL:  Yes, Madan.
                                           124

        >> DR. KUNDU:  We got disconnected.

        >> LAUREL:  Are we going on a break?

        >> DR. KUNDU:  Yes, Dr. Nemeth is answering the question about the family.

        >> DR. NEMETH:  So to answer the question, read Muriel Lezak's article.  I

   forgot to put it in the reference section.  Sorry.  But it's called Brain Damage

   is a Family Affair and she wrote it in 1988.  Anyone working with families of

   brain injured patients must have this article.  Must know it backwards and

   forwards and inside out.

        Okay, in my speech, in the handouts I talked about specific problems that

   families with brain injured patients have.  Number one is increased patient

   dependency, and this changes the family dynamics.

        Number two is cognitive inefficiency.  The person is not able to problem

   solve effectively.  Number three is social reaction to the patient's disability.

   Again, if a patient came back from the war with an arm cut off or a leg cut off,

   people understand that, but they don't understand why is it that this person who

   looks okay is acting weird.  So that's a problem for families.  Also emotional

   disturbances -- I can't tell you how many people have taken a look at traumatic

   brain injury and decided that that's not traumatic brain injury at all, it's

   just manic depressive illness.

        Now, what did Dr. Malec just say?  You see this disinhibition and

   depression as sequelae.  Does this mean the person was manic depressive

   premorbidly?  Probably not.  Does a person just magically as an adult coming

   back from the war become manic depressive?  No.  It's usually a sequelae of the

   brain trauma.

        Also executive disorders -- people who were once very capable of planning
                                           125

   and solving problems and inhibiting their behavior, of processing information,

   come back and can't do that anymore.  And then of course the obvious one is

   financial difficulties.  You know, maybe except for Bob Woodruff, I know of no

   brain injured family that is not having financial difficulty.  And so if you

   would look next -- at the next slide, it's about the changes that have to happen

   in the family, okay?  And one of the things that is important is we would

   specifically address this to brain injured veterans is our veterans, especially

   our Marines, are trained to be tough.  I mean, look at the ads on TV.  They are

   trained to be tough no matter what, to do it.  Navy seals, the same way.  So for

   these brain injured veterans to even begin to admit that they have a problem is

   a major issue.  They do not understand why they, who are now making no sense,

   cannot run the family.  Okay?

        So all of this has to be dealt with, not only for the brain injured person

   maybe individually and he or she should be in a group of brain injured people

   who are talking about the loss of roles that they now experience, but also there

   should be family therapy for these individuals.  And when I do family therapy

   for brain injured patients, I want every member of the family present, even if

   the youngest member is one year old because I want to see how the family handles

   and integrates that person.

        But one thing that's clear is these families have to develop a totally new

   notion of what's really important.  They must be closely networked.  They must

   communicate closely with one another.  They must be sensitive to the challenges

   that not only the brain injured person faces, but they themselves face, and lots

   of times extended family members don't get it.

        You know, in this country we are so used to "get over it."  We're so used
                                           126

   to having a short illness of some kind and then returning to full functionality.

   And what's important is to be open and honest with your friends and neighbors

   about what's really going on.  A lot of brain injured -- especially war veterans

   families -- want to hide this.  And then they have to develop an increased

   capacity to understand a perspective on the problem and, lastly, there has to be

   an enhanced ability to focus on, again, what's really important.  Families need

   to be taught to listen to the verbal and nonverbal; to communicate what is said

   and what is meant; to manage feeling, especially anger and anxiety; and most

   important -- this is something that we as a culture do not do well -- families

   need to learn to apologize to one another; to be polite and courteous and

   respectful.  Unfortunately, our American families have lost touch with that

   important element.

        So one of the things that I try to do -- and I wrote a book with two of my

   colleagues, Kelley Ray and Madell Sheknighter, and she is a graduate of this

   program, and she survived Dr. Kundu's wonderful guidance in regard to her

   masters thesis, okay?  And so I think very well of her, but we wrote a book

   called the RILEE Path to Family Intervention.  And RILEE is an acronym.  It

   stands for Relating In Love Every Evening because if you know anything about

   American families, you know that there is no time in the morning.  Okay?  We

   have to keep people on the RILEE path where we teach them to be polite and

   courteous, where we teach them to respect one another, to trust one another, to

   have comfort with one another and move toward love.

        What's happening, and that's what I cited in my comments about the men who

   have returned from the war only to murder family members is what's happened is

   they get so irritable and angry and they move to the angry side of relating and
                                           127

   this eventually leads to violence.

        So we have to teach families how to reattach and reintegrate into the

   family.  Then we have to teach them how to give positive attention, acceptance,

   approval, acknowledgment and affection, and this is harder in military families

   where most military fighting warriors have been taught not to show any of these

   behaviors.

        If any of you have ever watched the program on TV called The Unit, it's a

   good example of what I'm talking about.  And each and every time this special

   secret unit goes off, they are tough guys.  They do all kinds of things, you

   know, that they have to do.  And then they try to return to be loving members of

   their families and this transition is very hard.  And that's demonstrated in

   that program.  And just think those people who are displayed or portrayed on

   that program -- none of them have a brain injury.  So you can imagine how hard

   it really is for our brain injured military families.

        But family therapy, vocational rehabilitation is crucial.  It has to be

   done for a long time, not a short time.  I hope that addresses that issue.

   Dr. Kundu, do you want me to address this one here?

        >> DR. KUNDU:  No.  We have a couple of questions for Ms. Cohen from the

   Department of Defense.  She already left for Washington, but we will get in

   touch with her and forward your E-mails regarding the question from Charles.

   (Inaudible) with our returning disabled veterans.  I can't answer the question,

   but I'll forward it to her and she will respond to that.

        And another one from Lawrence, a program manager, and you mentioned about

   the accessibility of the video.  Once again, I'll send it to Ms. Cohen to

   respond to that.
                                           128

        There is one from Linda that I'm listening to the webcast from South

   Dakota.  Is there a way I can (inaudible).  I can't answer that question at this

   time but will communicate with you.  We have to make sure that you have the

   program from the morning.  We'll think about it and let you know how to deal

   with that situation.

        All right, let's see what else.  Once again, another one from (inaudible)

   regarding the tape.  Once again we'll refer it to Ms. Cohen.  Okay, I cannot

   read all of this.  We need to get started for the next session --

        >> DR. NEMETH:  I have one more comment, and that is I did not list my

   E-mail in the program and so if anyone wants to be in touch with me, the easiest

   way to do it is dgnemeth@aol.com. or get it to Dr. Kundu and they'll get it to

   me.

             >> DR. KUNDU:  All right, let's get started.  Please take your seats.

   May I have your attention, please.

        Please take your seats.

        >> My name is Sue Hayes, a first year second semester graduate student here

   at Southern University.  I have the pleasure to welcome our next speaker, Ollie

   Cantos.

        He has been blind since birth and he serves -- and he is a J. D.  He serves

   as a special counsel, the acting assistant attorney general for civil rights in

   the United States Department of Justice.

        Originally commissioned by Attorney General Albert Gonzales in March 2006,

   Mr. Cantos recently returned to this post after having served two consecutive

   terms of service as assistant director of domestic policy at the White House.

        One of the highest placed persons with a disability in the federal
                                           129

   government today, Mr. Cantos began his work at the Justice Department in

   August 2004 when he was originally commissioned by Attorney General John

   Ashcroft as special assistant to the assistant attorney general for civil

   rights.  He was the first and only person ever to serve as general counsel and

   director of programs for the American Association of People with Disabilities.

   Mr. Cantos continues to write on a range of topics.  He is also in radio and

   television and in newspapers and magazines and has written articles of national

   circulation.  I'd like to welcome Mr. Cantos.

        [APPLAUSE]

        >> MR. CANTOS: Greetings to all of you, both those who are here at the

   university as well as those who are attending this symposium online.

        I would like to send you greetings on behalf of Grace Becker, acting

   assistant attorney general for civil rights at the U.S. Department of Justice.

   It is an honor to be here today, but for me personally, it is also a significant

   honor because I myself was once a recipient of vocational rehabilitation

   services from the great state of California.

        When looking at your responsibility as professionals in service to people

   with all types of disabilities, we invariably understand how it is that our

   spirit and commitment, the public service is what drives our energy forward as

   we seek to maximize opportunities for people with all types of disabilities to

   engage in gainful employment and ultimately to do their part to contribute to

   the social and economic lives of the communities in which they live.

        And in light of that broad focus, and that broad commitment on the part of

   each and every one of us, including those who are here who are students in the

   field of rehabilitation who seek some day to make an impact in their own right,
                                           130

   we also see how it is that we must look very carefully about our ethical

   responsibility to do what is right for those we serve.

        Ethics is of course something that we must always take seriously.  It is

   not to be looked at in a vacuum, but is rather integral to all of the decisions

   that we make, the actions we take, the words that we speak and the assertions

   that enable us to show those with disabilities that they, too, have a right to

   participate in society to every degree possible just as those without

   disabilities.

        Specifically, when we focus on today's area of focus, those who are

   veterans, who are returning from war, we recognize their service to this country

   by seeing the things they have done and the priceless sacrifices they have made

   in order to benefit all of us.  We all share, whether Republican, Democrat or

   Independent, no matter what our political persuasion, no matter what our

   backgrounds may be economically or otherwise, we all share the spirit of

   gratitude in thanking these Americans for what they have done to be of service

   to this country.  And when we look at how they have been of service to us, we

   have the ethical responsibility, indeed the sacred obligation, to be of service

   to them.

        And in looking at the many ways in which we must proceed, we must take this

   sacred ethical obligation and apply it daily to the things that we do.  So I now

   would like to draw your attention to the two articles that you have.  Those of

   you who are watching this online will be able to look at these handouts on the

   ILRU website, and those of you who are present here may have it in your folders.

        When you look at these articles, one of them is dedicated to a systemic

   approach to ensuring and finding ways to advance employment opportunities for
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   people with all types of disabilities.

        The second article is an article that specifically focuses on returning

   veterans and how it is that we within an employment context may be of support to

   those individuals.  So although I'm not going to go through every aspect of each

   of these two articles, I call your attention to them because in each of these

   pieces are invaluable resources and websites that you may use to dig deeper, to

   gain more information and these articles are specifically written to enable all

   of you to apply today the things that are to be done and to see how it is that

   you may move forward by networking with individuals in the field not only within

   the field of rehabilitation, but also with consumer organizations of and for

   people with disabilities as well as various veterans organizations.

        And in looking at the things that are in your materials, the thing that I

   ask all of you to remember is to understand the spirit of self-determination

   that has been at the bedrock of the civil rights community including those of us

   who have disabilities who seek to speak for ourselves, not only because we have

   that fundamental sense of self-respect, but also because of the spirit of

   knowing that we ourselves can and must determine our own destiny and must

   determine the course of our own lives.

        When that spirit of self-determination is applied to our lives and when it

   is combined with the support of social service providers, family and friends,

   fellow veterans as well as others, then we may continue to create a broad

   tapestry that will enable us to provide seamless services to those with

   disabilities as well as people with disabilities ourselves serving as examples

   of what it means to be having gainful employment.

        So I'd like to call to your attention a particular website that has a
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   listing of the 43 federally recognized veterans organizations.  If you go to

   this information, you can go to www.hireamericanheros.mil is one website and

   another is www.americasupportsyou.mil and a quick correction,

   hireamericasheros.org.  And so when you look at these particular websites -- and

   there is another website that I would also suggest you look at, one has to do

   with opportunities within the federal government by veterans actually continuing

   to work for the military within a military context.  And that's at

   www.militaryjobs.org, and there is also www.opm.gov/veterans.

        So when you look at those websites, it's also important to see how it is

   that you can see the different resources that are available to you there.  And

   then when you look forward also, there is another website that has been put

   together by the veterans administration which may have been discussed earlier

   but it is worth pointing out again which is www.vetsuccess.gov and for those who

   are veterans who want to pursue building their own businesses as entrepreneurs

   there is www.vetbiz.gov.

        And now as we proceed to look forward, the other thing that is important to

   know in addition to these specific resources is what are the different hiring

   authorities that have been put into place to support veterans?  As well as

   people with other -- as well as people with disabilities in general.  One thing

   to understand, and it's also available in the materials, is there are different

   veterans programs that are available like the Veterans Recruitment Act and as

   well as 30 percent hiring for service connected disabilities, and there is also

   Schedule A hiring authority which is specifically targeted towards bringing more

   people with disabilities into federal government employment, and there are three

   targeted areas within this context.  One are those with physical disabilities;
                                           133

   the second are those with psychiatric disabilities; and the third are those who

   the statute refers to as those with mental retardation, but we refer to it more

   commonly today as those with intellectual disabilities.

        When people have appointment under Schedule A, it is to the benefit of

   those in the federal government who are hiring managers quite specifically

   because those individuals who qualify under Schedule A and who are considered

   job ready may be brought into the federal government noncompetitively.  And for

   those who are in the vocational rehabilitation field, it is important here to

   understand how much Schedule A has not been utilized as much as should be the

   case.  If any of you need sample language for a Schedule A hiring authority, you

   can get in touch with me by E-mailing me at ollie.cantos@usdoj.gov and my

   telephone number is (202)514-8191, voice or TTY.

        In addition, as you work to continue to build support for veterans who are

   returning from war, it is also important for you to know how it is that you may

   reach out to different nonprofit organizations in your local communities.  To

   date, there are more than 600,000 nonprofit organizations in this country

   according to the I. R. S. through the Form 990 that they happen to fill out and

   all of that information is collected through a nonprofit effort at

   www.guidestar.org.  There all of you will be able to find information about the

   organization, website, phone number, fax number, mission statement, most three

   recent accomplishments, projected goals, board members and other information.

        You may also look up organizations based on zip code, radius around zip

   code of 5, 10 or 25 miles, budget, and type of budget.  And best of all, you may

   combine these various search parameters for your individual purposes.

        And another website that all of you would do well to look at is to look at
                                           134

   a website which is actually of our partners today, the Independent Living

   Research Utilization project is headed under the leadership of Lex Frieden who

   is the former chair of the National Council on Disability which is an

   independent agency making recommendations to Congress and the President on

   necessary changes to national disability policy.

        That website of course all of you online obviously know it, but for those

   of you who are here it's at www.ilru.org.  And on that website you will find the

   various independent living centers that are located in communities of every size

   all across this country that provide services for people with didn't types of

   disabilities.

        There is also the National Association of Councils on Development

   Disabilities.  You can go to www.nacdd.org to identify the state DD council that

   is pertaining to your particular state or territory and from there you may link

   to other entities to which those state DD councils are linked.

        And the other thing that is also important is to look at the needs of those

   with psychiatric disabilities.  And here is a website that many folks go to --

   it is not the only website, but one is www.nami.org, that's the National

   Alliance on Mental Illness and it's important here to understand whatever I talk

   about those with psychiatric disabilities, for all of us here especially looking

   at life within an ethics context, we must specifically understand that just

   because a person has a psychiatric disability does not necessarily mean that he

   will, quote, go postal on somebody.  Those of us who are in the field of work

   with people with disabilities understand that fully well.  However, we must work

   to educate the broader community to help people understand that those with

   psychiatric disabilities are not necessarily a danger to themselves or others
                                           135

   and also the whole aspect of medication is yet another area within the

   psychiatric disability field where some choose to take medication and some do

   not.  And there is an ongoing debate as to whether and to what extent medication

   should be used, but for the purposes of this discussion, we must make sure to

   maximize dialogue with members of this particular subconstituency of the

   disability community.  Particularly for those who may have been traumatized by

   war who return and have psychiatric disabilities as a result.  We must not

   stereotype those individuals to somehow think that they are necessarily going to

   cause damage to themselves or to their families, but instead, in the same way

   that we reach out to all of our veterans, we must maximize opportunities for

   those individuals.

        For those with learning disabilities, such as dyslexia and other such

   disabilities, there is a wonderful website that you can go to which is

   www.ldonline.org.  That website has information of importance within an

   educational context and it also has information about the nature of learning

   disabilities and how disabilities may be accommodated.

        Speaking of accommodations, there is a central website that has been

   supported by the U.S. Department of Labor's Office of Disability Employment

   Policy called the Job Accommodations Network.  That is an important website both

   for those you serve as well as for all of you who are colleagues within the

   various professions serving those with disabilities.  That's at www.jan.wvu.edu

   and for further information about the U.S. Department of Labor's Office of

   Disability Employment Policy, you can go to www.dol.gov/odep.

        And so when looking at these various aspects of employment, we have looked

   already at the systemic approach.  We started off by looking at areas for
                                           136

   recruiting people with disabilities and how it is that you can engage in

   dialogue with organizations of and for people with disabilities.  We have then

   discussed employment resources and ways to move forward that ensure and to

   provide more opportunities for people with disabilities both within and outside

   government and then we have provided you with information about accommodating

   people with different types of disabilities.

        So fast forward, let us assume for the purposes of the remainder of this

   discussion that individuals now are employed.  So now I'd like to switch gears

   and the second article that discusses the Uniformed Services Employment and

   Reemployment Rights Act or USERRA, that's an article that I'll be jumping

   through from time to time.  But at this juncture it is important for to you

   understand what USERRA is.  Essentially employers, whether in or outside of

   government and of any size may not discriminate against people who end up

   serving in the armed forces.  That is important because there have been

   instances in which individuals have left because they were called to active duty

   and because of their departure they end up losing their jobs when they return.

   But what's important for all of us to understand is that those who are either

   reservists or active military service, those individuals have a right to return

   to their old jobs and to return in a way that puts them where they would have

   been had they not left on deployment in the first place.  And those who are

   covered under this law include those who are reservists, those who are in active

   duty and others.  And it is also next important in understanding the scope of

   USERRA is to know what essentially the requirements are under USERRA.

        In order to fall under antidiscrimination protections under USERRA, there

   are several requirements.  One requirement is that the job to which the person
                                           137

   is returning has to be civilian in nature.  And the job itself should be long

   lasting in nature as opposed to jobs that are simply meant to simply be

   temporary.  So, in other words, for jobs -- for civilian jobs in which there is

   an indefinite period of hiring where the person is expected that they will be

   hired or working there for an indefinite time until they leave, those are the

   types of jobs that are protected under USERRA.

        The other requirement to keep in mind here is that while the person is on

   the job, they actually must provide oral or written notice of them being part of

   the armed services, and here the only exception is if it is against military

   necessity or otherwise unreasonable.

        A third requirement is that the total period of service with some notable

   exceptions in your handout, the total period of service must not exceed five

   years.

        And basically the exceptions include if there is a time of national

   emergency or there is a national security situation that arises, or there is

   another instance in which they are otherwise called to duty and they answer that

   particular call.

        The fourth requirement under USERRA is that the person must not be

   discharged under conditions that are other than honorable.  And the material

   discusses what the qualifiers are, but essentially those who are honorably

   discharged are those who are protected under USERRA as well.

        And the fifth requirement is that upon completion of the military service,

   when folks come home, they must then report to work to their civilian job within

   specific time periods based on the length of time of their cumulative service.

   So if a person has been in cumulative service for one to 30 days, then that
                                           138

   individual -- that individual must report to work by the next work period within

   roughly 24 hours or so.

        If the person has been in service for more than 30 days but less than --

   but up to 180 days, that individual has 14 days to report back to work.  And for

   those who are in military service of 180 days or more, they have 90 days to

   report back to military service.

        There are some things that your materials point out where there are times

   in which that clock stops.  Let's say for example, if they happen to attain a

   service connected disability, then that time period may be extended for two

   years and there are some other requirements that I can talk with various of you

   offline if you have any specific questions.

        So the next question is what is one to do if he or she feels that his or

   her rights are violated under USERRA?  The thing to do is get in touch with the

   Veterans Employment and Training Service at www.vol.gov/vets.  And there you

   will learn more about how you may file a claim and the Department of Labor's

   Veterans Employment and Training Service actually looks at and analyzes the

   various complaints that come in and at the discretion of that department -- of

   that particular part of the Department of Labor, what next happens is some cases

   may then be sent to the Civil Rights Division of the U.S. Department of Justice

   and when it reaches us, we then evaluate it on the merits.  And what is

   interesting for these particular purposes is that USERRA authority was granted

   to us in 2004 and since then we've filed at least 14 cases under USERRA, and the

   first class action case utilizing USERRA as the foundational law that is really

   of critical importance.

        And so when we look at that, we think it's important here to understand
                                           139

   that when the attorney general or one of his designees represents the person who

   is allegedly harmed under USERRA, that attorney actually serves as the

   individual's attorney in the same way that that individual would end up having

   an attorney in a private context.  In this particular case, that attorney

   represents that specific person.  That is a rather unique aspect of law within

   this particular context.

        And so when looking at these areas, the next thing I wanted to go through

   here is to give you the specific website that you can go to for federal

   government information on disability issues in general.  And you can go to

   www.disabilityinfo.gov.  And to learn more about other laws that I won't be

   going through -- other laws in a moment, including the Americans with

   Disabilities Act, and The Rehabilitation Act of 1973 and other important laws,

   you may go to www.ada.gov.  And there you will see more information of

   importance to people with disabilities.  And you'll also be able to see the

   various accessibility requirements when it comes to places of public

   accommodation, state and local government and other such important areas.

        When it comes to USERRA enforcement, there is one other thing I would like

   to mention, and that is that if an individual is a federal employee, then that

   case is brought not necessarily through the Department of Labor's veterans

   employment and training service, but instead under the Office of Special Counsel

   at www.osc.gov.  And if there is a situation in which they find there to be

   merit, then those individuals who are federal employees may have their cases

   heard in front of the merit systems protection board at www.mspb.org.

        And so in light of the various resources that I have actually presented to

   you, the thing that we call upon each and every part of this profession to do,
                                           140

   not only is to continue to engage in active dialogue with members and leaders of

   the disability communities, but also to listen substantively to the things that

   everyone has to say and to put those things into practice.

        The other thing that I would like all of you to do is to think about ways

   to work creatively with us at the Civil Rights Division of the U.S. Department

   of Justice.  I've already given you my direct E-mail address as well as my phone

   number, and I would like to invite all of you to stay in touch with me and if

   you would like to be added to my leadership list in which I communicate on a

   regular basis on some of the latest developments within the disability rights

   field, you can E-mail me, but in the subject of the E-mail, entitle your subject

   leadership list addition.  And that will enable me to know the nature of the

   E-mail so that way I may add your information as quickly as possible.

        Also the material on veterans that I gave you through this list that I have

   just described, I will be soon sending out an expanded version that will include

   even more information of importance to veterans as well as to others with

   disabilities.

        So we today look at so many different areas, and I've attempted to cover as

   much of it as I could within the time limit that we happen to have, but the

   thing that I really would love to emphasize to you very, very strongly is that

   we at the Civil Rights Division of the Justice Department to the very highest

   levels, including Acting Assistant Attorney General Grace Becker, have a deep

   and abiding commitment to upholding and defending civil rights for people with

   all types of disabilities.  That is why we have also provided you with

   information not just from the Justice Department, but also from other federal

   agencies from across government and we have also provided you with information
                                           141

   from the nonprofit sector as well because those are individuals with whom we

   collaborate on a regular basis.

        As you go through the material that we have provided you, if there are

   additional resources that you feel should be added, please feel free to let me

   know because both of the articles that you have received are organic in nature

   and from time to time we update those pieces in order to maximize impact on

   members of the disability community in a truly, truly positive way.

        And now as I close, I'd like to say to all of you as a quick brief

   reminder, that all of you in a very real sense serve as gatekeepers in a

   specific context.  There are those who may come to you within the context of

   services that they seek and without your assistance they may not necessarily be

   in as good of a position to move ahead.  That's why it is important not only to

   have compassion, but also to have a progressive philosophy of disability, not

   feeling as if disability is necessarily a tragedy from which folks may not

   recover, but instead in recognizing that when people with different types of

   disabilities are given training and basic skills and the opportunity to succeed

   and when they know how much you each individually and collectively believe in

   them, they will then be in a better position to empower themselves to take their

   lives to the next level by obtaining the training necessary for them to compete

   in the workplace, and then once they arrive at the workplace, then to be able to

   excel and to grow and to be promoted and then as we see these efforts, they may

   serve as they already do.  They may serve as sources of significant inspiration

   to all of us because when we look at how we are truly inspired by those who have

   given so very much, including those who have lost their very lives, we also

   recognize that our helping America's veterans also has a significant societal
                                           142

   implication because our helping them enables us then to empower them to help

   their families.  And by strengthening the family and by making sure that they

   also receive the support that they need, then they may also grow to their

   greatest potential and we may in our words as well as in our deeds show how

   grateful we are and not only simply by saying it, but by combining our words

   with our actions that show how grateful we are.

        Thank you very much for the opportunity to be here and I hope we have

   enough time for questions.  [APPLAUSE]

        >> DR. KUNDU:  We have a question from the audience.  Yes, ma'am.

   Dr. Nemeth.

        >> AUDIENCE MEMBER: (inaudible).

        >> MR. CANTOS:  The question that was asked is that in light of USERRA

   having been passed and signed into law in 1994, October 13th specifically,

   when folks had come back here, they had ended up losing their jobs and she was

   asking if that was the reason why the law was passed.  That may be among many

   reasons, but the most significant reason why the law was passed is quite simply

   because to this very day people who return who are either reservists or who are

   veterans are not given the proper treatment that they rightfully deserve.  And

   that's why we need you as well as others to make sure to share with us instances

   in which there are alleged or possible violations of USERRA.

        There was actually a case here in Louisiana against Five Star Janitorial

   Company as an example where there was an individual, a part of the armed

   services, and he was discriminated against and the Justice Department has taken

   action and that is just one of a number of cases that takes place around the

   country, but it is important in order to maximize enforcement of USERRA and it
                                           143

   is a top priority of ours, in order to maximize, it is important that you let us

   know when situations come up so that way we may work on being as decisive as we

   can in helping to enforce their rights.

        >> DR. KUNDU:  Any other questions from here?  Laurel, do you have any

   questions?  Hello?

        >> DAWN:  Not at this time.

        >> DR. KUNDU:  Okay, all right.

        [APPLAUSE]

        >> I'm an associate professor on faculty in the rehabilitation counseling

   program here at Southern University.  I'm pleased to introduce our next

   presentation.  This presentation will discuss the Vocational Rehabilitation and

   Employment Program in the Veterans Affairs.

        First presenter is Roger Otzenberger.  He is a rehabilitation counselor in

   the Department of Veterans Affairs in Shreveport, Louisiana.  Roger served in

   the Air Force in the mid '80's and then later he earned his bachelors degree in

   rehabilitation counseling here at Southern University.  Following that, he

   worked for the Texas Rehabilitation Commission prior to accepting -- taking a

   position of a rehabilitation counselor at the Veterans Affairs.

        Assisting Roger will be LaSandra Dudley.  She is an employment coordinator

   with the Department of Veterans Affairs.  She also served in the military and in

   the '80's and 90's.  Following that, she earned her bachelors degree in

   psychology and a masters degree in social work and has work experience in

   clinical social work and she's completing her masters degree in vocational

   rehabilitation.

        I am pleased to welcome Roger Otzenberger and LaSandra Dudley.
                                           144

        >> MR. OTZENBERGER: I'm a little nervous.  I know it's late in the day.

   I'll try to be as efficient with your time as possible.  Yes, ma'am -- speak up?

        Can you hear me now?  I'd like to begin by first having a word on ethics

   and performance standards in the field of rehab -- rehabilitation, and then

   conclude with that by going over the Chapter 31 Vocational Rehabilitation and

   Employment Program with you.

        As we continue to move into the 21st century, VR counselors are faced

   with many challenges and are held highly accountable as well as the agencies we

   work for in making sure that quality services are provided to the consumers or

   veterans we serve.

        Funding is therefore also critical and performance standards are necessary

   to make sure the money is spent judiciously.  Sometimes there appears to be a

   nebulous bond between ethics standards and the current performance measurement

   system that does not provide an accurate picture of measuring the delivery of

   individualized services.

        I am sure most here are familiar with the preamble and ten canons of ethics

   as described by CRCC.  As we can see, there are many perhaps areas of rehab

   ethics we could discuss or explore as counselors.  Not only does CRCC set

   ethical guidelines for us to follow, but we set our own unique standards and the

   agencies that we work for set policies on ethics and performance standards as

   well.

        These performance standards are necessary and keep us conscientious of our

   objectives.  When we as VR counselors come across laws, regulations or

   performance standards set by our agencies, we sometimes question the

   practicality, not necessarily the ethical intent of a standard that has been set
                                           145

   by our agency.  Yet sometimes the two appear to conflict with one another.

        For example, the standard is that counselors may only have 12 percent or

   less of all cases in their case load interrupted at any one time.  I know that

   my fellow VR counselors know that a lot of times we have no control over the

   interrupted rate of our cases.

        We have only 115 days from the time a case goes to evaluation and planning

   to actually write the plan.  Many times due to the complexity of issues,

   coordination of services and comprehensive evaluations needed, especially when

   working with veterans or individuals with more catastrophic injuries or

   disabling conditions such as independent living cases, 115 days is simply not

   enough time to develop a comprehensive plan and to coordinate the services that

   the veterans need.

        We as counselors know that many times this is not reasonable and not really

   fair to the clients we serve either.  Writing plans for the sake of writing

   plans for the consumers we serve is neither practical or ethical.  However,

   because of performance standards, counselors sometimes are confronted with the

   ethical issue of meeting performance requirements or meeting the needs of the

   veterans or the clients that we serve.

        But performance standards require a plan to be written for 80 percent of

   those coming into our program.  However a prematurely written plan often sets

   the veteran or consumer up for failure and in no way can be considered practical

   or ethical.

        Therefore, some venues in which we provide counseling constantly call for

   greater leadership as counselors as opposed to the agencies in which we are

   employed.  Often this may create a cognitive difference and result in a behavior
                                           146

   or frankly a change in jobs or agencies because we feel an ethical standard has

   been violated.  However, the laws which govern the V.A., Chapter 31 Vocational

   Rehabilitation Program I believe offer enough latitude in many cases for a

   counselor to work within his or her ethical framework.

        To give you an example, when I worked for Texas Rehab, their performance

   standards initially required that we have so many successful rehabs per year.

   And then it became so we had to have so many successful rehabs per quarter.

   Then we had to have so many successful rehabs per month.  The counselor would

   get a letter of counseling the first time they didn't meet that standard for the

   month.  And they would get a letter of warning the second time and the third

   time they were fired.

        For many counselors, this created a lot of burnout.  And of course

   counselors went and found other jobs.  And this had a feeling among the

   counselors of -- I hate to say it -- but of being a used car salesman.  We were

   writing plans just to write plans just to make the numbers.  For me as a VR

   counselor, this is not ethical or practical.

        Of other importance, our veterans and clients also affect the accuracy of

   these interruptions and discontinued rates by not showing up for their

   appointments or not following through with a counselor's request.  Clients

   should also have a shared responsibility for the rehab process so that rehab

   services are more efficient and effective.  We want to empower our veterans and

   our clients, not create dependency when appropriate.

        On the other hand, an example of necessary performance standards that

   measurement entitlement determination is a great standard.  You want to let our

   clients know as quickly as possible whether or not they are entitled to the
                                           147

   program.  So to me that's great measurement.

        We have a responsibility as vocational rehabilitation counselors to respect

   the rights and reputation of any institution, organization or firm which we are

   associated with and should attempt to affect changes through constructive action

   within the organization as indicated in Canon 1 under moral and legal standards.

   Most of us are on the front line and know firsthand what is practical and what

   is ethical at the same time.

        We have a responsibility to affect change in a positive way that is clearly

   more advantageous to the people and to the veterans that we serve.  And this is

   better for the clients and chances are it's more ethical as well (inaudible).

        The V.A. Chapter 31 vocational rehabilitation program believes in early

   intervention as fundamental and as an ethical step in providing rehabilitation

   services, particularly for those disabled and transitioning from the military.

   The following presentation is a summary of that information disseminated to

   those veteran members to motivate them to apply for rehabilitation services and

   to determine the most appropriate level of service that they may need.

        (No audio).

        Vocational Rehabilitation Employment Program, the primary function is to

   help veterans who have service connected disabilities become suitably employed

   to maintain employment or achieve independence in daily living and help maximize

   their independence in daily living.

        Chapter 31 is an employment program and we stress employment program.  Not

   many years ago our program was known as vocational rehabilitation counseling

   program.  We have changed that to vocational rehabilitation with emphasis on

   employment for veterans with disabilities and provides eligible veterans who are
                                           148

   found to be entitled to the program because of their service connected

   disability, the ways and means of overcoming a disability and assist them in

   obtaining and maintaining gainful employment.

        We're going to talk about the difference between eligibility and

   entitlement.  What we need to remember -- sometimes I know with other agencies

   you may get the two confused, Chapter 31 and the other V. A. educational

   programs is totally different than the Chapter 31 rehabilitation program.  We

   are an employment program whereas Chapter 30 is the GI bill and they have ten

   years from the date they are discharged to use it.

        Chapter 31 is an employment program.  (inaudible) service connected

   disability for being in receipt of military retired pay in lieu of disability is

   considered entitlement to rehabilitation employment services.

        So a veteran -- a veteran may be eligible if he has a compensable service

   connected disability to apply for the program at 10 percent or higher, but it

   doesn't necessarily mean they are entitled to the program.  That's why we have

   vocational rehab counselors to make the determination to see whether or not the

   veteran may or may not, they may have an employment handicap.

        Again, Chapter 31 is an employment program.  Training must be considered

   reasonable and feasible.  We want to make sure -- remember the ultimate goal of

   our program is employment for our veterans.  We want to make sure ultimately in

   the end that our veterans that we're assisting, that they are employable.  If

   they are not employable, we have to assess them for independent living needs or

   an independent living plan at the time.

        Under the Chapter 31 program, our veterans -- if they are approved for a

   training program will pay for tuition and the books and the supplies.  They also
                                           149

   receive an allowance each month and the rate of that subsistence allowance

   depends on how much they are going to school.  Veterans have 12 years from the

   date of their discharge to also apply for Chapter 31 vocational rehabilitation

   program.  If it's beyond their entitlement determination date, beyond the 12

   years, they would have to be found with a serious employment handicap versus an

   employment handicap.

        Chapter 30, they'll get an allowance of $1,100 per month each and every

   month.  They can use it for whatever they want, whatever program of course they

   want to go into, whatever degree program.  They have ten years to use it and

   have up to 36 months of entitlement.  Whereas with Chapter 31, we pay for all

   the tuition, the books, the allowance and also receive, as I mentioned earlier,

   an allowance which depends on the rate of the veteran and you have 12 years to

   use your benefits then you get up to 48 months of benefits.  But I want to

   stress that if a veteran comes and say are approved to go through a program in

   computer-aided design or associate degree, that that's their primary vocational

   objective.  So they can't come back a month later and say I've got 36 months

   left or 20 months left I want to use that to go do something different.

        Veterans become eligible for the program as I mentioned earlier from the

   date they are notified of their service connected disabilities and they have 12

   years from that date to use Chapter 31.  Except for those who may have a serious

   employment handicap, you may be able to extend that date.

        An employment handicap means an impairment that results in substantial

   (inaudible) from the veterans disabling condition.  A service connected

   disability need not be the primary cause of the employment handicap, but it must

   materially contribute to the impairment.
                                           150

        A serious employment handicap and a significant impairment results in

   substantial (inaudible) from a service connected disability.  A lot of things we

   look at when we talk about serious employment handicap is long term

   unemployment, chronic long term mental health problems, homelessness, lack of

   developed skills or education, criminal record -- those are things we are

   looking for that affect our veterans in gaining suitable competitive employment.

        Suitable training is defined as training that is commensurate with the

   veteran's overall interests, aptitudes, overall abilities and limitations.

   Those ineligible for our program are veterans who do not have a compensable

   service connected disability.  You have to have a service connected disability

   to be compensated for that disability to be able to receive services under the

   Chapter 31 program.

        Those veterans who are determined not to have an employment handicap or

   have an employment handicap, but have no expired eligibility determination date

   does not meet the criteria for (inaudible).  Those are veterans not entitled to

   Chapter 31.

        This is the point where LaSandra, my colleague, is going to come up and

   talk about the five tracks to employment.  Thank you.

        >> MS. DUDLEY:  Good afternoon everybody.  As Mr. Otzenberger just said,

   once an entitlement determination is made, the veteran sits down with a voc

   rehab counselor and assesses interests, aptitude testing may be done.  We get to

   the point where the veteran will enter a track which will lead them to

   employment.

        The five tracks to employment are reemployment, access to employment,

   self-employment, employment through long term services and our independent
                                           151

   living track.

        Okay, so reemployment -- this plan is designed for those individuals

   separated from active duty on National Guard or Reserve to which they return to

   their previous employment and Mr. Cantos told us all about the USERRA act.

   That's the track where we are most active in using the USERRA or working with

   employers through USERRA.  This track may involve job accommodations, job

   modifications, case management, coordination and linkage to outside services

   like VAMC in consultation with the employer.

        I have been told my voice is not that loud.  Bear with me.  That's our

   reemployment act.  This is where those veterans come and they want to go back --

   they want to go back to their previous employers.  They don't want to try to go

   and be retrained or go to a different field.  That's the reemployment track.

        Okay, our access to employment -- this plan or this track is targeted to

   those individuals who have expressed a desire to seek employment soon after

   separation or who already have the necessary skills to be competitive in a job

   market in an appropriate occupation.

        When a veteran comes to voc rehab, they generally cannot do the things that

   they were able to do before they were on active duty.  In this aspect, these

   veterans have other skills that they can utilize and they don't need to be

   retrained.  So in this track, the veteran may be provided with some job

   readiness preparation, resume development, development of employment resources

   and job accommodations and post-employment follow-up.  We make sure everything

   is going right on the job like the lady this morning was talking about, the job

   accommodations.  We provide those if they need any, follow up with the employee

   to make sure they are going to be successful at their job.
                                           152

        The self-employment -- this track is targeted to individuals who have

   limited access to traditional employment.  They need a flexible work schedule or

   they need more accommodating work environment due to their disabling conditions

   or other life circumstances.  So they can't do a traditional 9 to 5 as the V.A.

   is concerned, 7:30 to 4.  They have to work when they can, when their

   disabilities allow them to.

        These people are generally in two categories.  And the category depends on

   the amount of services that we can provide while they are in the self-employment

   track.  Category one veterans to be entitled to this program of self-employment,

   a veteran must be determined to have a most severe service connected disability.

   Essential services will be provided as required to enable the veteran to obtain

   and maintain self-employment.  So we would help them with (inaudible).  To see

   what all they need to do, how they can be successful in their business, we'll

   provide them with some of the startup equipment and so that they can get started

   and follow them for a year while they're in the self-employment plan.

        The category two is targeted to individuals who have an employment handicap

   or serious employment handicap but their disabilities are not determined to be

   the most severe.  Limited self-employment services are provided such as life

   insurance assistance which a person assumes a veteran will need to begin

   employment.  For example, we have some veterans who go into the home inspection

   arena.  That is essentially a self-employment track, but we don't help them

   develop their business plan, but we will provide them with -- to help them get

   their license, any tools like a ladder, special tape measures, those kind of

   things they need and if they were going into business, the nature of that

   business is self-employment, but they don't necessarily have that serious --
                                           153

   that severe most severe disability they can do that.

        Employment through long term services -- this plan -- this track is

   targeted to individuals who need specialized training or education to obtain and

   maintain suitable employment.  Like I say, most veterans when they come into the

   voc rehab program, they come because they are at a certain level of functioning

   vocationally before they went on active duty and now they can't do that.  So for

   these people who go into this track, they are found to not have any transferable

   skills sufficient enough to reenter the workforce.  So they will go through a

   long term training -- when I say long term training, it doesn't always mean a

   four year college or a masters level.  It could be long term meaning however

   long it takes to get through that suitable goal for that veteran.  So it could

   be an OJT, apprenticeship, job monitoring, job partnering or higher education if

   deemed necessary.

        Another program we have which falls into this track is called the Non-Paid

   Work Experience program, and we generally refer to it as the NPWE and I don't

   have a slide for that one.  The NPWE is where the V.A. will contact eight

   federal or local government agencies because the goal of the NPWE is to help a

   veteran to get some recent experience on their resumes.  We have veterans who

   know how to do jobs for example of administrative assistant.  We have veterans

   who have that prior experience, but they don't have any recent experience on

   their resume.  So what we would do is partner with those government agencies.

   We would place that veteran in that agency.  We would pay that veteran for going

   to work in that agency.  While they are in that agency working, we will provide

   them with all the medical, dental services they need so that they can, number

   one, build up their confidence so when they are ready to look for work, they
                                           154

   have that recent experience and they know that I can do this job.  The recent

   experience will also give them more experience or more exposure to different

   technologies they weren't exposed to previously.  So that further enhances their

   employability.  Like I say, the agency doesn't pay anything.  We pay everything

   so that we get this veteran including a level of employability as needed for

   them to reenter the job market.

        The next track (inaudible).  The question is are the families compensated

   as well while the veteran is going through this program?  Unfortunately, no, the

   family is not.  Because it's a program geared to get the veteran back to

   employment, we are only limited in providing our monthly allowance to that

   veteran while he's in the program -- he or she is in the program.

        The allowance that they get like Mr. Otzenberger was saying earlier depends

   on the number of hours.  Well, because they will be getting work experience,

   they'll get all the full time hours but the allowance also depends on the number

   of dependents you have.  So you'll get paid a little bit more in your allowance

   because you have dependents.

        >> MR. OTZENBERGER: The allowance for veterans, they have to be service

   connected --

        >> MS. DUDLEY: The question is if the veteran has to be rated at 30 percent

   or higher to get an additional allowance in their allowance.  That is a

   different benefit.  We have a compensation check which veterans are entitled to

   based on their disability, their level of disability.  In that part of it, a

   veteran who is rated 30 percent or higher would get -- they won't get any

   additional money for dependents unless they are rated at 30 percent or higher.

   However, in the voc rehab program, it doesn't matter if the veteran is not
                                           155

   30 percent.  They will still get their allowance based on the number of

   dependents they have.

        And our last track is our independent living services.  This track is

   targeted to individuals who may not be able to work right now and need

   rehabilitation services to live more independently.  So this may include

   assistive technology, independent living skills training and connections to

   community-based support services.  Although the track to employment -- it's just

   saying that right now the veteran cannot work.  However, we have some veterans

   who once they get their basic needs met or basic accommodations taken care of,

   they can -- that might put them in a position to be empowered to get suitable

   employment like Ms. Dinah this morning was talking about, the lady who was

   talking this morning.  With the assistive technology, it gave her the confidence

   and the ability to go back to work.  Well, in the independent living track we

   address those issues, those basic issues that the veteran needs and that they

   have to consider before even considering going to work which will then possibly

   take them to that level where they could reach a viable vocational goal.

        >> AUDIENCE MEMBER: (Inaudible).

        >> MS. DUDLEY:  For our veterans -- the question is where is that service

   provided in Louisiana?  Within our program, the veterans -- like Mr. Otzenberger

   said, our program is geared to those veterans with service connected

   disabilities.

        >> AUDIENCE MEMBER: (Inaudible).

        >> MS. DUDLEY:  We have our New Orleans regional office is in (inaudible).

   That's located at 671 Whitney Avenue.  However, you can get in touch with us at

   1-800-827-1000 and you can ask to speak to someone in the vocational
                                           156

   rehabilitation and employment division.  We also have --

        >> AUDIENCE MEMBER: (Inaudible).

        >> MS. DUDLEY: We have two -- basically two offices, one in the New Orleans

   area and one in Shreveport.  So those are the only two areas that we have any,

   and you'll have to come to one of those.

        >> AUDIENCE MEMBER: (Inaudible).

        >> MS. DUDLEY: If deemed necessary, we will come to that veteran's home

   because sometimes we have to coordinate services or the vocational

   rehabilitation counselors have to coordinate services or adapted home services

   for the veteran.  So, yes, in a lot of independent living cases, it is possible

   that the vocational rehabilitation counselor will need to go to that home and do

   an assessment of the home.

        (Inaudible).

        >> MS. DUDLEY: The question was is the budget separated from the vocational

   aspect to the independent living aspect, and because I am the employment

   coordinator, I'm not really prepared to answer that question.  However, my

   supervisor is here and she can answer that question for me.

        (Laughter).

        >> AUDIENCE MEMBER: (Inaudible).

        >> In response to your question about budgetary constraints, when someone

   is under Chapter 31, vocational rehabilitation program, we are not restricted by

   budget constraints in terms of providing them a service because we use what we

   call readjustment benefits.  And so we -- at this level, at the counselor's

   level, the VRC's position, there are some monetary constraints in terms of maybe

   construction and other services.  However, if we as counselors have deemed that
                                           157

   a particular service is necessary and vital to this particular veteran, then if

   it goes over our signature authority of 25,000, we then refer it to our

   vocational rehabilitation officer and he signs off on it.  If for some reason it

   goes beyond $75,000, then it goes to our central office in Washington.  And

   that's the only constraint that we have.  But it's not like two separate pots of

   money.

        >> AUDIENCE MEMBER: (Inaudible).

        >> That is a figure that -- okay, sorry.  His question was what are the

   figures I was referring to when I said $25,000 and $75,000?  Those are program

   authorization figures.  The 25,000 is what a VR counselor has under their

   signature that they can sign off and allocate for a particular case in a given

   year.

        The 75,000, if there is a program that is going to go over the $25,000,

   then we have to give it to our vocational rehabilitation employment officer, and

   he has to sign off on it.

        >> AUDIENCE MEMBER: (Inaudible).

        >> A case, yes.

        >> AUDIENCE MEMBER: (Inaudible).

        >> Okay.  Again, those services don't automatically come to everybody.

   We're talking about the independent living program and some of the things

   that -- because independent living services may be more expensive and more

   higher cost, there are things that you have to look at and justify so that as

   Mr. Otzenberger as a counselor said, we need to have an evaluation when we go

   out to a veteran's home and that evaluation at his home says he needs some

   modification.  Mr. Otzenberger can only sign off on $25,000.  So if there is
                                           158

   something that goes beyond that, it has to go to a higher level of authority to

   authorize that.

        Any other questions before I leave?

        >> AUDIENCE MEMBER: (Inaudible).

        >> MR. OTZENBERGER: I think the question was the difference between or how

   do you determine eligibility?  And there is a distinction between eligibility

   and entitlement to Chapter 31.  Eligibility only means that a veteran -- a

   veteran is eligible to apply for vocational rehab and has a compensatory service

   connected disability.  That's the eligibility part of it.

        The entitlement part of it comes when a V. R. counselor has to sit down

   with the individual and the veteran and make a determination that they have an

   employment handicap or serious employment handicap.  Because not every veteran

   that applies for our program will have a handicap or serious employment

   handicap.  There is a difference and even with the veterans, even for me at the

   beginning, the terminology sometimes of the V.A. can be misleading to some

   degree.

        >> AUDIENCE MEMBER: (Inaudible).

        >> MR. OTZENBERGER: Right, a compensable service connected disability at

   10 percent or higher are eligible to apply but only a VR counselor can make that

   determination.

        >> AUDIENCE MEMBER: (Inaudible).  Please compare your -- I think you can

   hear me from here.  Severe disability and most severe disability, how does that

   compare with VR agencies with severe and most severe -- you've worked in the

   state VR and have a sense of severe disability and most severe.  Severe and most

   severe for the V. A., is it similar to that?  And secondly when you talk about
                                           159

   30 percent disability and 40 percent disability, is that determined by the

   counselor or is the physician the one that determines the percent of disability?

        >> MR. OTZENBERGER: The compensation is determined by the Veterans Service

   Center.  Compensation would make that determination on what a veterans service

   connected percentage was.  We have nothing to do with that.  We have absolutely

   nothing to do with that part of it.

        >> AUDIENCE MEMBER: (Inaudible).

        >> MR. OTZENBERGER: Carolyn.  (Inaudible).

        >> His question was who assigns the rating disability?  The vocational

   rehabilitation program is divided into Veterans Service Center and under the

   Veterans Service Center, we have rating specialists.  They refer cases to the

   V.A. Medical Center or to specialized contractors for a rating decision.  And

   they are the ones who make the decision to determine whether a rating is

   10 percent vs. 30 percent.  It is dependent upon the medical finding of

   functioning and how that disability impacts the veteran.

        >> AUDIENCE MEMBER: (Inaudible).

        >> No, no, if the physician that the V.A. uses that the Veterans Service

   Center uses who then forwards his information back to the Veterans Service

   Center.  And based upon the documentation from the medical standpoint, the

   language that the medical physicians uses, the rating decision-maker assigned a

   percent to that disability.  And then that in turn equates to what that veteran

   gets in terms of monetary compensation on a monthly basis.

        >> AUDIENCE MEMBER: (Inaudible).  If I lose one arm, is that a certain

   rate?  If I lose one eye, is that a certain rating?

        >> Yes, the question is if he loses an arm, is that a certain rating and
                                           160

   how will we compare that with workman's compensation and private insurance?  I

   can't tell you about workman's compensation or private insurance, but I can tell

   you that as far as the V.A. is concerned, a lost arm equates to a certain

   percentage of a disability rating.  And the Veterans Service Center has a huge

   volume of references to allocate those particular disability ratings.  So the

   services that you're asking about really come under our rating board in the

   Veterans Service Center and for us on the other side in terms of vocational

   rehab, all we need is that veteran to have a service connected disability rating

   to be eligible to be considered for vocational rehabilitation services.  Once

   the consideration takes place and based upon information the veteran shares with

   us and assessments that we conduct on the veteran, we then make the

   determination that the veteran either has vocational rehabilitation barriers

   that prevent him from getting employment and then we work with him or her to

   provide ways to overcome those barriers to employment.

        Now, those specific ways that we determine to overcome the barriers are

   really dependent on the individual's needs.  For one person, it may be long term

   training.  For another one, it just may be certification of six months or

   testing.  So it really is a very individualized program.  In terms of the

   services we provide, some services to veterans may last up to a time period of

   48 months.  Other services may just be as short as six months because it is

   dependent upon the veteran's individual needs to get back into the workforce.

   Yes?

        >> AUDIENCE MEMBER: (Inaudible).

        >> Education is -- again, is not something we advocate in terms of just

   going through education.  We advocate or provide for academic training as a
                                           161

   means to an end.  We will provide you the academic training you need to get

   competitive entry level employment.

        >> AUDIENCE MEMBER: (Inaudible).

        >> If there is a documented need, if you as a student document that you

   need a particular book via your syllabus, we will provide that particular item

   for you.  If as a student, under our program, you say you need -- you have a

   documented need for whatever service, a medical refer for dental, you'll be

   given that particular referral.  So our role is to assist you in overcoming the

   barriers to your employment.  If you identify those to us and we document that

   those are barriers, then we will provide you the service to overcome those

   barriers.

        >> AUDIENCE MEMBER: (Inaudible).

        >> That is correct.  You have to sit down with your counselor.  You have to

   meet with your counselor, and again when we talk about assessments, that's what

   we're talking about, identifying what your needs are so when a rehabilitation

   plan is written for you, it identifies these specific services so that you're

   aware the length of time, the amount of service and what your expectation for

   assistance can be and you're aware of what our expectations are for you in order

   to keep those services coming.

        >> AUDIENCE MEMBER: (Inaudible).

        >> We have a real great website, and it is very informative.  It connects

   you to other links and it is a very good source of information about all the

   V.A. programs, but it's a great one about our rehabilitation program as well.

        >> AUDIENCE MEMBER: (Inaudible).

        [APPLAUSE]
                                           162

        >> DR. KUNDU: Well, give a round of applause to our speakers.

        [APPLAUSE]

        >> DR. KUNDU: Well, what a wonderful day with a lot of information.  So I

   would like to give some presentations to our speakers, a memo from Southern

   University.  Dr. Nemeth, would you come forward, Dr. Malec, Ollie, there we go.

   Roger.  LaSandra.

        Thank you very much for your patience throughout the day.  We enjoyed

   having you here.  I know you came from all different distances from Monroe,

   Shreveport, and give them a round of applause for being here.

        [APPLAUSE]

        >> DR. KUNDU: And I would like to extend my thanks to the faculty, graduate

   students, Nikki Wilson for the symposium, Alo Dutta, everybody.  Thank you.

        [APPLAUSE]

        >> DR. KUNDU: Have a safe trip.

        >> LAUREL: Madan, for those of us who aren't there, what did you give the

   speakers?

        >> DR. KUNDU: We gave some little coffee cups of Southern University, blue

   and gold color.  So the cup is blue color, and on the outside is the university

   logo of the jaguar.  So blue and gold is our colors.  They will have their

   morning coffee with our cup.

        >> LAUREL: With a jaguar.

        >> DR. KUNDU: That's correct.

        >> LAUREL: Madan, thank you for letting us be a part of this conference.

        >> DR. KUNDU: Thank you for all the participants throughout the country or

   wherever they may be in another part of the world.  I think this was a nice
                                           163

   experience for us to have that webcast at the same time and definitely we'll do

   better the next time.

        >> LAUREL: It went very well.  And just one bit of closing, we will have

   the entire webcast, the entire program archived plus there will be a transcript

   as well as the audio and the handouts on our website from now on.  It will be

   there for the rest of our lives.  How about that, and so anybody who is

   interested can come back to it.  Go ahead.

        >> DR. KUNDU: The National Clearinghouse, they will do whatever technical

   format so it will be available from their website, too, but they will link up to

   our website.  So that anyone can go to your website, our website, they will be

   able to get it.

        >> LAUREL: Excellent.  And they are doing the podcast, right?

        >> DR. KUNDU: Correct.

        >> LAUREL: That's excellent.  Thank you a lot -- it's rare that we

   civilians get to do anything in support of the service men and women who are

   safeguarding us, and so we appreciate this opportunity.  It's a wonderful

   program, Madan.

        >> DR. KUNDU: Also the reporter from the local newspaper, so there might be

   something in the newspaper tomorrow.

        >> LAUREL: That's just great.  Nice job, Madan, and Alo did a wonderful

   job.

        >> DR. KUNDU: Bye.